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Patient Safety Learning

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News posted by Patient Safety Learning

  1. Patient Safety Learning
    We’re living in an unprecedented time and facing new challenges. We’re asking questions we’ve never had to ask before – questions that differ according to our unique circumstances, concerns and needs.
    With an increasingly complex health and social care system, Patient Safety Learning wants to continue working towards a future that is safe for both patients and staff.
    It’s for this reason that we’ve launched Oscar, the friendly health chatbot. Available on the hub, Oscar answers the public’s question about their safety – or that of their family members and friends – during the coronavirus pandemic.
    Oscar is not a diagnostic tool. We at Patient Safety Learning are not medical experts ourselves, but we want to connect patients to the best guidance currently in the public domain. This is what Oscar seeks to do, in pointing visitors to helpful and trustworthy answers, relevant to their specific situations.
    Whether you’re a well adult seeking general information about how to stay safe from coronavirus, a concerned woman about to give birth and wanting to know your options, or a carer looking for advice, Oscar is here to help you find the answers you need. In time, as we see how the public uses Oscar – and especially as we hear your feedback – we plan to build on the range of information Oscar currently offers. 
    Like everything else on the hub, Oscar is free to use.
    Please do send us any feedback, including information you’d like Oscar to provide, by emailing feedback@pslhub.org
  2. Patient Safety Learning
    The government and NHS England appear unable to identify units set up to treat ‘long covid’, contrary to a claim by Matt Hancock in Parliament that the NHS had ‘set up clinics and announced them in July’. 
    There are growing calls for wider services to support people who have had COVID-19 and continue to suffer serious follow-up illness for weeks or months. Hospitals run follow-up clinics for those who were previously admitted with the virus, but these are not generally open to those who were never admitted.
    Earlier this month the health secretary told the Commons health committee: “The NHS set up long covid clinics and announced them in July and I am concerned by reports from Royal College of General Practitioners that not all GPs know how to get into those services.”
    Asked by HSJ for details, DHSC and NHS England declined to comment on how many clinics had been set up to date, where they were located, how they were funded or how many more clinics were expected to be “rolled out”.
    However, two charities and support groups — Patient Safety Learning and the Long Covid Support Group — told HSJ they were not aware of dedicated long covid clinics for community patients. An enquiry from Patient Safety Learning to NHS England has not been answered.
    The number of people affected by long covid is unclear due to a lack of research but there are suggestions it could be half a million or more. Symptoms can include fatigue, sleeplessness, night-time hypoxia, “brain fog” and cardiac problems. It appears to affect more people who were not hospitalised with coronavirus than those who were were. There is some evidence that small clinics have been set up locally on a piecemeal basis, without national funding.
    HSJ has only been able to identify only one genuine “long covid clinics” open to those who have never been in hospital with covid. 
    Trisha Greenhalgh, an Oxford University professor of primary care health sciences who has interviewed around 100 long covid sufferers, told HSJ: “Nobody I have interviewed had been seen in a long covid clinic but there is an awful lot of people who would like to be referred and who sound like the need to be but they haven’t.”
    Read full story (paywalled)
    Source: HSJ, 23 September 2020
    Read the letter Patient Safety Learning sent to NHS England
    hub Community thread - Long Covid: Where are these clinics?
     
  3. Patient Safety Learning
    The NHS 111 helpline for urgent medical care is facing calls for an investigation after poor decision-making was linked to more than 20 deaths.
    Experts say that inexperienced call handlers and the software used to highlight life-threatening emergencies may not always be safe for young children. At least five have died in potentially avoidable incidents.
    Professor Carrie MacEwen, Chairwoman of the Academy of Medical Royal Colleges, said: “These distressing reports suggest that existing processes did not safeguard the needs of the children in these instances.”
    Since 2014 coroners have written 15 reports involving NHS 111 to try to prevent further deaths. There have been five other cases where inquests heard of missed chances to save lives by NHS 111 staff; two other cases are continuing and one was subject to an NHS England investigation.
    Read full story (paywalled)
    Source: The Times, 5 January 2020
  4. Patient Safety Learning
    A “commended” NHS nurse has been awarded nearly £500,000 for being wrongly sacked after she claimed that high workloads led to a patient’s death.
    Linda Fairhall, 62, a 44-year veteran of the health service, said she made 13 separate pleas to bosses warning that her colleagues were overburdened, but she was ignored each time.
    Fairhal told officials at the University Hospital of North Tees and Hartlepool that she was worried about a recently imposed policy that obliged nurses to monitor patients who took prescribed medicines and maintained that it led to nurses having to conduct 1,000 extra patient visits a month without extra resources.
    She said nurses were overwhelmed by the additional responsibility, which resulted in rising “anxiety” among staff and higher rates of absence. However, Fairhall told the tribunal in Teesside that nothing was done in response to her concerns, and ultimately a patient died.
    The tribunal heard that the nurse raised her last warning with officials just before she went on annual leave. On her return she was suspended and investigated for “bullying and harassment”, then sacked for gross misconduct.
    A tribunal has now ruled that the decision to dismiss Fairhall was “materially influenced” by her complaints regarding patient safety, with the panel adding that it could not “genuinely believe” that she was guilty of misconduct.
    Read full story (paywalled)
    Source: The Times, 4 January 2023
    Read the full tribunal decision: Ms L Fairhall v University Hospital of North Tees and Hartlepool Foundation Trust
  5. Patient Safety Learning
    Relatives of patients who died after receiving "dangerous" levels of painkillers at Gosport War Memorial Hospital have called for new inquests. 
    An inquiry found 456 patients died after being given opiate drugs at the hospital between 1987 and 2001, but no charges have ever been brought.
    Four families told the BBC they have requested judge-led "Hillsborough-style" hearings with a jury. The Attorney General's Office said it was reviewing the application.
    Police began a fresh inquiry in 2019 into 700 deaths after the Gosport Independent Review Panel found there was a "disregard for human life" at the hospital in Hampshire.
    Coroner-led inquests in 2009 found drugs administered at the hospital contributed to five deaths.
    However, lawyers representing some of the families told the BBC more wide-ranging inquests similar to those that examined the events of the Hillsborough disaster should be undertaken.
    Read full story
    Source: BBC News, 5 February 2021
  6. Patient Safety Learning
    Great Ormond Street Hospital (GOSH) failed to properly investigate child deaths, suggests evidence uncovered by the BBC.
    The source of one fatal infection was never examined and in another case GOSH concealed internal doubts over care. Amid claims GOSH put reputation above patient care, former Health Secretary Jeremy Hunt urged it to consider a possible "profound cultural problem".
    Responding, the central London hospital said it rejected all suggestions that it treated any child's death lightly.
    BBC Radio 4's File on 4 programme has spoken to several families whose children were treated at the world-famous hospital. All said that while care at one point had been excellent, when things went wrong GOSH appeared to have little interest in fully understanding what had happened.
    The concerns over how Great Ormond Street is run are shared by staff. A staff survey, published last month, made grim reading for management.
    On two aspects, including whether there is a safety culture, it received the lowest score of all trusts in its category, while on three other questions, including how bad bullying and harassment were, and how good the quality of care was, its own staff rated it as among the worst.
    "If we want the NHS to offer the highest quality care in the world, then we have to change a blame culture and sometimes a bullying culture, for a learning and an improvement culture," the former Health Secretary Jeremy Hunt told File on 4.
    "That staff survey would indicate they don't have that culture at Great Ormond Street."
    Read full story
    Source: BBC News, 17 March 2020
    Read Joanne Hughes' response to this news in her blog shared on the hub.
  7. Patient Safety Learning
    The high proportion of pregnant women from black and ethnic minority (BAME) groups admitted to hospital with COVID-19 "needs urgent investigation", says a study in the British Medical Journal.
    Out of 427 pregnant women studied between March and April, more than half were from these backgrounds - nearly three times the expected number. Most were admitted late in pregnancy and did not become seriously ill. Although babies can be infected, the researchers said this was "uncommon".
    When other factors such as obesity and age were taken into account, there was still a much higher proportion from ethnic minority groups than expected, the authors said.
    But the explanation for why BAME pregnant women are disproportionately affected by coronavirus is not simple "or easily solved," says Professor Knight, lead author.
    "We have to talk to women themselves, as well as health professionals, to give us more of a clue."
    Gill Walton from the Royal College of Midwives says, "Even before the pandemic, women from black, Asian or ethnic minority backgrounds were more likely to die in and around their pregnancy,"
    She said they were "still at unacceptable risk" and getting help and support to affected communities was crucial. 
    Ms Walton added: "The system is failing them and that has got to change quickly, because they matter, their lives matter and they deserve the best and safest care."
    Read full story
    Source: BBC News, 8 June 2020
  8. Patient Safety Learning
    On January 2020, Patient Safety will be on the G20 agenda (among other five health key priorities), but Abdulelah M. Alhawsawi, Saudi Patient Safety Center, asks "what is patient safety doing on an economic forum like the G20?"
    Patient harm is estimated to be the 14th leading cause of the global disease burden. This is comparable to medical conditions such as tuberculosis and malaria. In both US and Canada, patient safety adverse events represent the 3rd leading cause of death, preceded only by cancer and heart disease. In the US alone, 440,000 patients die annually from healthcare associated infections. In Canada, there are more than 28,000 deaths a year due to patient safety adverse events. In low-middle income countries,  134 million adverse events take place every year, resulting in 2.6 million deaths annually. 
    In addition to lives lost and harm inflicted, unsafe medical practice results in money loss. Nearly, 15 % of the health expenditure across Organization of Economic Cooperative Development countries is attributed to patient safety failures each year, but if we add the indirect and opportunity cost (economic and social), the cost of harm could amount to trillions of dollars globally.
    When a patient is harmed, the country loses twice. The individual will be lost as a revenue generating source for society and the individual will become a burden on the healthcare system because he or she will require more treatment. Unless we do something different about patient safety, we would risk the sustainability of healthcare systems and the overall economies. 
    Alhawsaw proposed establishing a G20 Patient Safety Network (Group) that will combine Safety experts from healthcare and other leading industries (like aviation, nuclear, oil and gas, other), and economy and fFinancial experts
    This will function as a platform to prioritise and come up with innovative patient safety solutions to solve global challenges while highlighting the return on investment (ROI) aspects. 
    This multidisciplinary group of experts can work with each state that adopts the addressed global challenge to ensure correct implementation of proposed solution.
    Read full story
    Source: The G20 Health & Development Partnersip, 10 February 2020
  9. Patient Safety Learning
    Four carers have been found guilty of ill-treating patients at a secure hospital, following a BBC Panorama investigation.
    Nine former staff at Whorlton Hall, near Barnard Castle, County Durham, had faced a total of 27 charges. Five of those on trial have been cleared.
    Jurors heard vulnerable patients were mocked and treated with "contempt".
    Lawyers for the defendants argued their clients had been doing their best in very challenging circumstances.
    The men found guilty have been bailed and will be sentenced at Teesside Crown Court in July.
    Speaking after the verdicts, Christopher Atkinson, of the Crown Prosecution Service, said the four men had a "duty of care for patients who, due to significant mental health issues, were wholly dependent on their support every day of their lives".
    He said it was "clear" there were times when the care provided was "not only devoid of the appropriate respect and kindness required but also crossed the line into criminal offending".
    Read full story
    Source: BBC News, 27 April 2023
  10. Patient Safety Learning
    Frontline NHS staff in England will have to be fully vaccinated against Covid, the health secretary has announced.
    A deadline is expected to be set for 1 April next year to give unvaccinated staff time to get both doses, Sajid Javid told the Commons.
    Between 80,000 and 100,000 NHS workers in England were unvaccinated, said Chris Hopson, head of NHS Providers.
    Thursday is the deadline for care home workers in England to get vaccinated.
    The government's decision follows a consultation which began in September and considered whether both the Covid and flu jabs should be compulsory for frontline NHS and care workers. Mr Javid said the flu vaccine would not be made mandatory.
    There will be exemptions for the Covid vaccine requirement for medical reasons, and for those who do not have face-to-face contact with patients in their work, he added.
    In a statement to MPs, Mr Javid said: "Having considered the consultation responses, the advice of my officials and NHS leaders including the chief executive of the NHS, I have concluded that all those working in the NHS and social care will have to be vaccinated."
    "We must avoid preventable harm and protect patients in the NHS, protect colleagues in the NHS and of course protect the NHS itself."
    Read full story
    Source: BBC News, 9 November 2021
  11. Patient Safety Learning
    An NHS England review into the behaviour of high-profile senior leaders who took over a Midlands trust has concluded that the interim CEO “behaved poorly and inappropriately” while its chair was “complicit with” and failed to address problems.
    NHS England had commissioned an independent probe into allegations about the behaviour of new executives, who had recently been appointed to the board of Walsall Healthcare Trust.
    David Loughton and Professor Steve Field, who hold the same roles at the Royal Wolverhampton Trust, were brought in as interim chief executive and chair respectively in spring 2021.
    Walsall has faced care quality concerns for some years and it was hoped the pair from neighbouring Wolverhampton would bring improvements. 
    Dr McLean wrote in her review: “Leadership changes can, understandably, represent a period of anxiety for those affected but this can be minimised if changes are made in line with appropriate values and processes. 
    “Whilst I conclude that the joint chair and interim CEO were motivated to act in the best interests of patients, I was saddened by much of what I heard.
    ”In the narratives I heard, there was a consistent lack of compassion or respect for people.”
    She concluded: “The interim CEO, while motivated by the safety and care of patients, has behaved poorly and inappropriately … the joint chair has been complicit with and failed to address this behaviour.”
    Read full story (paywalled)
    Source: HSJ, 2 February 2022
  12. Patient Safety Learning
    NHS staff are failing to follow guidelines for providing care to sickle cell patients - and some of the advice has been branded as “unfit for purpose”.
    The NHS Race and Health Observatory commissioned research, undertaken by Public Digital, to explore the lived experience of people undergoing emergency hospital admissions for sickle cell and managing crisis episodes at home.
    The Sickle cell digital discovery report: Designing better acute painful sickle cell care, found that the existence of service-wide information tailored by the National Institute for Health and Care Excellence has “arguably not been designed for an ambulance, A&E and emergency setting”, and states it has been proven that this guideline is “not being used and adhered to consistently”.
    Moreover, healthcare professionals have warned that the National Haemoglobinopathy Register (NHR) -  a database of patients with red cell disorders - is not being readily accessed, while patients reported being treated in a way that breached prescribed instructions.
    “We believe that sickle cell crisis guidelines could be improved in terms of their usability in a high-pressure emergency setting, and in terms of promoting access to them,” the report authors concluded, adding that current guidance should be adapted.
    Read full story
    Source: The Independent, 31 January 2023
  13. Patient Safety Learning
    More than half a million people have accessed online training that aims to prevent suicide in the last three weeks alone, a charity has said.
    The Zero Suicide Alliance said 503,000 users completed its online course during lockdown. It aims to help spot the signs that a person may need help.
    It comes as health leaders warned front-line workers tackling coronavirus could suffer from mental ill health.
    NHS England launched a mental health hotline to support staff last month.
    The alliance's Joe Rafferty said the true impact of the coronavirus on mental health will not be known until the pandemic ends, but he said "the stress and worry of the coronavirus is bound to have impacted people's mental health".
    Read full story
    Source: BBC News, 18 May 2020
  14. Patient Safety Learning
    Academy-style hospitals will be set up to improve patchy NHS leadership under a shake-up planned by Sajid Javid to deal with post-pandemic waiting lists.
    The health secretary is formulating the reorganisation to give well-run hospitals more freedom as well as forcing failing trusts to improve. A new class of “reform trust” will be established as Javid signals an appetite for wide-ranging changes to deal with a “huge” variation in performance across the health service.
    Modelling reforms on the Blairite academies programme could lead to failing hospitals being forcibly turned into reform trusts, as happens with schools that are rated inadequate. It is possible that chains of hospitals will be run by leading NHS managers, or even outside sponsors, although this is yet to be decided.
    Boris Johnson is said to want to focus on cutting NHS waiting times as part of an “operation red meat” designed to shift the focus from rows over Downing Street parties. Allies of Javid say, however, that his desire for reform long predates the prime minister’s present problems and that as the Omicron wave recedes he believes he has a “six-month window” to introduce changes before planning for next winter takes over.
    His proposals raise the prospect of ministers embarking on another NHS reorganisation, even before the government’s Health and Care Bill — itself designed to reverse previous Tory reforms – becomes law.
    The plans are still at an early stage but are due to feature in a white paper that will set out Javid’s plans for dealing with weak leadership and slow adoption of best practice in parts of the NHS. A Whitehall source said: “Sajid’s reform agenda is all about driving up performance across the NHS. To achieve that we are going to apply some lessons from the academies programme.”
    Read full story (paywalled)
    Source: The Times, 18 January 2022
  15. Patient Safety Learning
    People with learning disabilities have been given do not resuscitate orders during the second wave of the pandemic, in spite of widespread condemnation of the practice last year and an urgent investigation by the care watchdog.
    Mencap said it had received reports in January from people with learning disabilities that they had been told they would not be resuscitated if they were taken ill with COVID-19.
    The Care Quality Commission (CQC) said in December that inappropriate Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) notices had caused potentially avoidable deaths last year.
    DNACPRs are usually made for people who are too frail to benefit from CPR, but Mencap said some seem to have been issued for people simply because they had a learning disability. The CQC is due to publish a report on the practice within weeks.
    The disclosure comes as campaigners put growing pressure on ministers to reconsider a decision not to give people with learning disabilities priority for vaccinations. There is growing evidence that even those with a mild disability are more likely to die if they contract the coronavirus.
    Read full story
    Source: The Guardian, 13 February 2021
  16. Patient Safety Learning
    The Health and Social Care Committee has launched a new inquiry to examine leadership, performance and patient safety in the NHS.
    Inquiry: NHS leadership, performance and patient safety
    MPs will consider the work of the Messenger review (2022) which examined the state of leadership and management in the NHS and social care, and the Kark review (2019) which assessed how effectively the fit and proper persons test prevents unsuitable staff from being redeployed or re-employed in health and social care settings.
    The Committee’s inquiry will also consider how effectively leadership supports whistleblowers and what is learnt from patient safety issues.
    An ongoing evaluation by the Committee’s Expert Panel on progress by government in meeting recommendations on patient safety will provide further information to the inquiry.
    Health and Social Care Committee Chair Steve Brine MP said:
    “The role of leadership within the NHS is crucial whether that be a driver of productivity that delivers efficient services for patients and in particular when it comes to patient safety.
    Five years ago, Tom Kark QC led a review to ensure that directors in the NHS responsible for quality and safety of care are ‘fit and proper’ to be in their roles. We’ll be questioning what impact that has made.
    We’ll also look at recommendations from the Messenger review to strengthen leadership and management and we will ask whether NHS leadership structures provide enough support to whistleblowers.
    Our Expert Panel has already begun its work to evaluate government progress on accepted recommendations to improve patient safety so this will build on that. We owe it to those who rely on the NHS – and the tax-payers who pay for it – to know whether the service is well led and those who have been failed on patient safety need to find out whether real change has resulted from promises made.”
    Terms of Reference
    The Committee invites written submissions addressing any, or all, of the following points, but please note that the Committee does not investigate individual cases and will not be pursuing matters on behalf of individuals.   Evidence should be submitted by Friday 8 March. Written evidence can be submitted here of no more than 3,000 words.   How effectively does NHS leadership encourage a culture in which staff feel confident raising patient safety concerns, and what more could be done to support this? What has been the impact of the 2019 Kark Review on leadership in the NHS as it relates to patient safety? What progress has been made to date on recommendations from the 2022 Messenger Review? How effectively have leadership recommendations from previous reviews of patient safety crises been implemented? How could better regulation of health service managers and application of agreed professional standards support improvements in patient safety? How effectively do NHS leadership structures provide a supportive and fair approach to whistleblowers, and how could this be improved? How could investigations into whistleblowing complaints be improved? How effectively does the NHS complaints system prevent patient safety incidents from escalating and what would be the impact of proposed measures to improve patient safety, such as Martha’s Rule? What can the NHS learn from the leadership culture in other safety-critical sectors e.g. aviation, nuclear? Read full story
    Source: UK Parliament, 25 January 2024
  17. Patient Safety Learning
    Patient safety campaigners have said ‘too many women’ are still not being offered a general anaesthetic for a diagnostic test because of staff shortages, leaving them in severe pain.
    A survey by the Campaign Against Painful Hysteroscopies found around 240 women – which equates to 80 per cent of respondents – who had a hysteroscopy since the start of 2021 said they were not told they could have a general anaesthetic prior to the procedure.
    This suggests the situation has only improved marginally since 2019, when the campaign group first started collecting data. A spokeswoman from the campaign group called the pain being endured by women “barbaric” and said staffing shortages need to be addressed.
    Guidance from the Royal College of Obstetricians and Gynaecologists said all pain relief options, including general anaesthetic, should be discussed.
    Helen Hughes, chief executive of Patient Safety Learning, said: “We are hearing from too many women that they are not being given the full information about the procedure. It damages their trust and makes them worry about accessing future services.”
    She said: “It’s distressing that despite what we know, [the guidance] is not being implemented properly. Informed consent is essential for patient safety as well as a legal requirement.”
    Read full story (paywalled)
    Source: HSJ, 7 June 2022
    What is your experience of having a hysteroscopy? Share your experiences on the hub in our community forum.
    Further reading:
    House of Commons Debate - NHS Hysteroscopy Treatment Through the hysteroscope: Reflections of a gynaecologist Minister acknowledges patients’ concerns about painful hysteroscopies; but will action be taken? Improving hysteroscopy safety: Patient Safety Learning blog Outpatient hysteroscopy: RCOG patient leaflet
  18. Patient Safety Learning
    A draft NHSE statement suggests mental trusts could be asked to eradicate features of the ‘serenity integrated mentoring’ (SIM) care model from clinical practice, following a whirlwind of concerns in 2021 and an investigation by national clinical director Tim Kendall.
    A core feature of SIM is to place a police officer within a healthcare team charged with supporting patients who frequently attend emergency services in crisis, and creating crisis plans.
    The draft position statement produced by NHSE, which the regulator said is not its final version and is subject to changes, says SIM should not be used.
    It also proposes the eradication of the following practices from any equivalent care model:
    Police involvement in delivery of therapeutic interventions in planned, non-emergency, community mental healthcare; The use of coercion, sanctions (criminal or otherwise), withholding care and otherwise punitive approaches; and Discriminatory practices and attitudes towards patients who express self-harm behaviours, suicidality and/or those who are deemed “high intensity users”. The statement, which is the first indication of NHSE’s position on the SIM model but not its final stance, also suggests Professor Kendall will be seeking assurance from trust medical directors that SIM or similar models, and the above three features of concern, are no longer used. A full policy and public statement on the model is expected by the spring.
    The StopSIM coalition, whose campaigning prompted the NHSE review, said: “Unless and until the full policy is freely available to service users and the public, service users are not equipped to protect themselves against the dangers of SIM and similar approaches".
    Further reading on the hub:
    The High Intensity Network (HIN) approach and SIM model for mental health care and 'high intensity users' – views and discussion
    StopSIM: Mental health is not a crime
     
  19. Patient Safety Learning
    A damning inquiry into the Royal College of Nursing, the world’s biggest nurses’ union, has exposed bullying, misogyny and a sexual culture where women are at risk of “alcohol and power-related exploitation”.
    A 77-page internal report by Bruce Carr KC, leaked to the Guardian, lays bare how the RCN’s senior leadership has been “riddled with division, dysfunction and distrust” and condemns the male-dominated governing body, known as council, as “not fit for purpose”.
    Grave concerns are also raised about the RCN’s annual conference, known as congress, where Carr says an “inappropriate sexual culture” warrants further urgent investigation “to identify the extent to which [it] has actually resulted in exploitation of the vulnerable”.
    The eminent barrister reports that there is evidence to support the “impression” that senior individuals have been seeking to take sexual advantage of subordinates and “engaging in unwanted sexual behaviours”.
    He calls on those whose conduct is cited in the report, whom he does not name, to consider their positions in the light of testimony of groping, humiliation of female staff members and a refusal of those in positions of responsibility to reflect on the letters of resignation from women on the council, who have complained of “gaslighting and microaggressions”.
    Read full story
    Source: The Guardian, 10 October 2022
  20. Patient Safety Learning
    A miniature radar system that tracks a person as they walk around their home could be used to measure the effectiveness of treatments for Parkinson’s.
    The disease, which affects about 145,000 people in the UK, is linked to the death of nerve cells in the brain that help to control movement.
    With no quick diagnostic test available at present, doctors must usually review a patient’s medical history and look for symptoms that often develop only very slowly, such as muscle stiffness and tremors.
    The device, about the size of a wi-fi router, is designed to give a more precise picture of how the severity of symptoms changes, both over the long term and hourly.
    It sits in one room and emits radio signals that bounce off the body of a patient. Using artificial intelligence it is able to recognise and lock on to one individual. Over several months it will notice if their walking speed is becoming slower in a way that indicates that the disease is becoming worse. During a single day it can also recognise periods where a person’s strides quicken, which means that it could be used to monitor the effectiveness of new and existing drugs, even where the effects last a relatively short time.
    “This really gives us the possibility to objectively measure how your mobility responds to your medication. Previously, this was nearly impossible to do because this medication effect could only be measured by having the patient keep a journal,” said Yingcheng Liu, a graduate student at the Massachusetts Institute of Technology (MIT) who is part of the team behind the device. 
    Read full story (paywalled)
    Source: The Times, 22 September 2022
  21. Patient Safety Learning
    Doctors, scientists and researchers have built an artificial intelligence (AI) model that can accurately identify cancer in a development they say could speed up diagnosis of the disease and fast-track patients to treatment.
    Cancer is a leading cause of death worldwide. It results in about 10 million deaths annually, or nearly one in six deaths, according to the World Health Organization. In many cases, however, the disease can be cured if detected early and treated swiftly.
    The AI tool designed by experts at the Royal Marsden NHS foundation trust, the Institute of Cancer Research, London, and Imperial College London can identify whether abnormal growths found on CT scans are cancerous.
    The algorithm performs more efficiently and effectively than current methods, according to a study. The findings have been published in the Lancet’s eBioMedicine journal.
    “In the future, we hope it will improve early detection and potentially make cancer treatment more successful by highlighting high-risk patients and fast-tracking them to earlier intervention,” said Dr Benjamin Hunter, a clinical oncology registrar at the Royal Marsden and a clinical research fellow at Imperial.
    Read full story
    Source: The Guardian, 30 April 2023
  22. Patient Safety Learning
    Today is Global Handwashing Day, a global advocacy day dedicated to increasing awareness and understanding about the importance of handwashing with soap as an effective and affordable way to prevent diseases and save lives.
    hub content on handwashing:
    WHO: Guidance on engaging patients and patient organisations in hand hygiene initiatives
    Safety and Health Practitioner: Tips for hand hygiene 
    Hand washing dance - this is how we do it
    What initiatives are in your hospital to ensure "clean hands for all"? Share your tips on the hub.
  23. Patient Safety Learning
    Dr Henrietta Hughes was appointed as the first ever Patient Safety Commissioner for England in July. She began her role on 12 September.
    Dr Hughes is an independent point of contact for patients so that patients’ voices are heard and acted upon. She will use patients’ insight to help the government and the healthcare system in England listen and respond to patients’ views and promote patient safety, specifically with regard to medicines and medical devices.
    For more information on the role of the Patient Safety Commissioner see the fact sheet and the government’s response to a consultation regarding the post.
    The privacy notice sets out how the Patient Safety Commissioner collects and uses personal data to fulfil the role.
    Please contact the Patient Safety Commissioner at commissioner@patientsafetycommissioner.org.uk.
    Source: Department of Health and Social Care, 28 September 2022
  24. Patient Safety Learning
    Healthcare staff in the West Midlands have been told not to start chest compressions or ventilation in patients who are in cardiac arrest if they have suspected or diagnosed covid-19 unless they are in the emergency department and staff are wearing full personal protective equipment (PPE).
    The guidance from the University Hospitals Birmingham NHS Foundation Trust says that patients in cardiac arrest outside the emergency department can be given defibrillator treatment if they have a “shockable” rhythm. But if this fails to restart the heart “further resuscitation is futile,” it says.
    If a patient with suspected covid-19 is in cardiac arrest they should be given cardiac compressions and be ventilated only if they are in the emergency department and the person attending them is wearing aerosol generating procedures (AGP) PPE. That means wearing an FFP3 mask, full gown with long sleeves, gloves, and eye protection.
    The advice rests on the premise that performing cardiac compressions risks virus particles being released into the air that could infect staff.
    Read full story
    Source: BMJ, 29 March 2020
  25. Patient Safety Learning
    Only one NHS trust in England provides dedicated training to prevent sexual harassment, according to research, raising concerns that the NHS is failing to adequately protect staff and patients.
    According to health union figures, sexual harassment of staff is pervasive. A 2019 survey by Unison found that one in 12 NHS staff had experienced sexual harassment at work during the past year, with more than half saying the perpetrator was a co-worker. In a recent BMA survey, 91% of female doctors reported sexism, 31% had experienced unwanted physical contact and 56% unwanted verbal comments.
    Yet research by the University of Cambridge, published in the Journal of the Royal Society of Medicine found that the vast majority of NHS trusts did not provide any dedicated training to prevent sexual harassment.
    The report analysed data from freedom of information requests from 199 trusts in England and found that just 35 offered their workers any sort of active bystander training (ABT), while only one NHS trust had a specific module on sexual harassment.
    ABT is designed to give individuals the skills to call out unacceptable behaviour, from workplace bullying to racism and sexual misconduct. It is widely used by the military, universities and Whitehall, including the Home Office.
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    Source: The Guardian, 5 May 2023
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