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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Chris Elston, a patient safety education lead, shares how he used Safety Engineering Initiative for Patient Safety (SEIPS) and Accident Mapping (AcciMap) to learn from a patient safety incident at his Trust.
  2. Content Article
    Doctors working in temporary positions (known as locums) are a key component of the medical workforce and provide necessary flexibility and additional capacity for NHS organisations and services. There have been concerns about the quality and safety of locum practice and the way NHS uses locum doctors. The number of doctors working as locums, and the costs of this to the NHS have caused some concerns nationally in recent years. It has also been suggested that locum doctors may not provide as good a quality of care as permanent doctors. Research carried out by a team at the University of Manchester provided important new information on these issues. The findings indicated that locum working and how locums were integrated into organisations could pose significant challenges for patient safety and quality of care.
  3. Content Article
    NIHR Patient Safety Research Collaborations (PSRCs) are partnerships between universities and NHS trusts that support patient safety research. There are six PSRCs in England, aiming to bring patient safety discoveries to frontline NHS services.
  4. Content Article
    Fear of retaliation by leaders or colleagues can prevent staff from reporting adverse events, unsafe conditions, or near misses. This article presents strategies to improve just culture in the perioperative environment, which is prone to hierarchical structure. Strategies include creating an accessible reporting system, implementation of a "good catch" programme, and leadership support for staff who submit reports.
  5. Event
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    As we all know, Patient Safety remains an urgent global public health issue, pertinent to all health systems around the world. Among the most important advances in recent years, the WHO’s publication of the first Global Patient Safety Action Plan 2021-2030 stands out, a roadmap that is expected to guide member countries in making decisions and implementing different strategies and measures with the aim of safeguarding the safety of care as a central axis of health policies. The 2023 summit in Montreux marked another milestone in the series. It focused on implementing known measures and interventions. This is crucial to overcome the so-called implementation gap to further advance in strengthening patient safety . The Chile 2024 Summit will delve into how different countries have managed to implement and sustain over time different strategies related to delivering safe health care in the framework of the 7 strategic objectives of the Global Patient Safety Action Plan, key lessons learned in the implementation process, results obtained and upcoming challenges, with the aim of gathering this knowledge and transforming it into national commitments to address concrete actions. This is why the summit 2024 will follow the overarching slogan of “Bringing and maintaining changes in patient safety policies and practices”. Interested participants are welcome to register online https://psschile.minsal.cl/?page_id=945&lang=en#038;lang=en (English) and https://psschile.minsal.cl/?page_id=945 (Spanish) More information about the registration procedure, the programme, and speakers as well as on practical matters can be found on the website and will be continuously updated: https://psschile.minsal.cl/
  6. Content Article
    Around 1 in 5 children have eczema (also known as atopic eczema or atopic dermatitis). They typically have inflamed and dry, itchy skin. During flare-ups (periods of worsening symptoms), their skin becomes vulnerable to cracks, bleeding and infection. Eczema impacts quality of life; it can impair sleep, ability to concentrate at school, self-confidence and mood. The condition is usually long-term (chronic), although it improves, or even clears completely, in some children as they get older. Even so, it is one of the most common reasons for children and young people to seek medical care. Community pharmacists and GPs are the first port of call and, while there is no cure, treatments can soothe sore skin, reduce itching, improve the appearance of the eczema, and reduce infections.
  7. Content Article
    Diagnostic errors cause significant patient harm. The clinician’s ultimate goal is to achieve diagnostic excellence in order to serve patients safely. This can be accomplished by learning from both errors and successes in patient care. However, the extent to which clinicians grow and navigate diagnostic errors and successes in patient care is poorly understood. Clinically experienced hospitalists, who have cared for numerous acutely ill patients, should have great insights from their successes and mistakes to inform others striving for excellence in patient care.
  8. News Article
    A campaigner in Norfolk says the "deaths crisis" at the county's mental health trust is getting worse. Bereaved relatives met the mental health minister, Maria Caulfield, to discuss failings at the Norfolk and Suffolk NHS Foundation Trust (NSFT). The trust says it is on a "rapid, and much-needed journey of improvement". Mark Harrison, from the Campaign to Save Mental Health Services in Norfolk and Suffolk, said: "We judge people by what they do, not what they say." Members of the campaign group met Ms Caulfield and other MPs in Westminster on 12 March and demanded an independent public inquiry into the trust. It came after a report last summer which found that more than 8,000 mental health patients had died unexpectedly in Norfolk and Suffolk between 2019 and 2022. At the meeting, it was agreed Ms Caulfield would meet bosses at the NSFT. The health select committee will also be asked to conduct an inquiry into the trust as part of a broader public inquiry. But Mr Harrison said he had little confidence anything would change. "The deaths crisis is just out of control and it's accelerating," he said. "We have been doing this for 10 years. Every time somebody promises to do something, it doesn't come to anything." Read full story Source: BBC News, 20 March 2024
  9. Content Article
    SafetyNet brings together the collective efforts of the six NIHR Patient Safety Research Collaborations (NIHR PSRCs).across England in addressing patient safety challenges of strategic importance. The quarterly SafetyNet newsletter offers you the opportunity to find out about the exciting research and collaborations that are happening across the safety centres and wider organisations.
  10. Content Article
    These principles underpin how NHS services must approach concerns that are raised by staff, students and volunteers about health services.
  11. Content Article
    In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored side-lined or victimised. Why staff don’t speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Concluding with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.
  12. Content Article
    Currently, it is estimated that more than one in five people in the UK are living in poverty. This King's Fund analysis reveals that people living in poverty find it harder to live a healthy life, live with greater illness, face barriers to accessing timely treatment, and die earlier than the rest of the population. The analysis looks at the link between poverty and each of the following: prevalence of ill health difficulties accessing health care late or delayed treatment poorer health outcomes. The long read argues that while the NHS can, and should, do more to make timely care accessible to deprived communities, wider government and societal action is needed to address the root causes of poverty.
  13. Content Article
    Diagnostic delays in the emergency department (ED) are a serious patient safety concern. This retrospective cohort study included children treated at 954 EDs across 8 states, and examined the association between ED volume and delayed diagnosis of first-time diagnosis of an acute, serious conditions (e.g., bacterial meningitis, compartment syndrome, stroke). The researchers found that EDs with lower pediatric volume had higher rates of delayed diagnosis across 23 serious conditions. 
  14. News Article
    Millions of people with long-term illnesses should get medical treatment at home rather than in hospital to help them carry on working, according to a report. The NHS is being urged to deliver more medicines directly to patients’ doors, so they can self-administer drugs at home, and “get on with life” rather than having to travel back and forth to hospitals. New research shows this model of care, called clinical homecare, helps those needing regular treatment for chronic conditions, including cancer and arthritis, to stay in employment and retain independence. Experts said providing more patients with specialist medicines at home can play a vital role in tackling the UK’s growing rates of economic inactivity, with 2.7 million long-term sick now signed off work. The report, commissioned by the National Clinical Homecare Association, said expanding the schemes means millions of patients “could be supported to continue working and living their lives without being defined by their health status”, adding that up to three million cancer patients could benefit. Read full story (paywalled) Source: The Times, 19 March 2024
  15. News Article
    William Wragg, the Tory chair of the Public Administration and Constitutional Affairs Committee (PACAC), has belatedly intervened in the growing crisis over the failure of the Prime Minister to appoint a new Parliamentary Ombudsman to replace Rob Behrens who quits the Parliamentary and Health Service Ombudsman on 31 March 2024. In a letter published on the committee’s website, Mr Wragg asks Sir Alex Allan, the senior non executive director on the Parliamentary and Heath Services Ombudsman board, what measures will be taken to keep the office going and what is going to happen to people who, via their MP, want to lodge a complaint to the Ombudsman. He also raises whether reports can be published and complaints investigated. The letter discloses that recruitment for a new Ombudsman began last October and a panel chose the winning candidate at the beginning of January. Since then the Cabinet Office and Rishi Sunak, who has to approve the appointment, have not responded. The silence from Whitehall and Downing Street means no motion can be put to Parliament appointing a new Ombudsman, who then appears before the PACAC for a pre appointment hearing. PACAC has only a couple of weeks to set up the hearing. Read full story Source: Westminster Confidential, 12 March 2024
  16. News Article
    The chair of an inquiry into the deaths of mental health patients in Essex has said she is “disappointed” at a delay in having its scope confirmed by the health secretary. Baroness Kate Lampard said she has been unable to begin substantive work on the probe while still waiting for sign-off from government. An inquiry was launched in 2021 to review the deaths of at least 2,000 people in contact with Essex mental health services across a 20-year period. Baroness Lampard took over as chair last year after it gained new powers to compel people to give evidence, following concerns not enough staff were coming forward. She has proposed expanding its scope by a further two years until 2022 due to ongoing concerns and to cover NHS patients treated in the private sector. The final terms of reference will be set by the health secretary Victoria Atkins. Baroness Lampard said she has not heard back from the Department of Health and Social Care on her proposals since submitting them three months ago. Read full story (paywalled) Source: HSJ, 19 March 2024
  17. Content Article
    The Government is in the process of reforming the way that health and care professionals are regulated. It is planning to change the legislation for 9 out of the 10 healthcare professional regulators that the Professional Standards Authority (PSA) oversees, giving them a range of new powers and allowing them to operate in a very different way. The changes the Government intends to roll out will give regulators greater freedom to decide how they operate, including introducing the flexibility to set and amend their own rules. There will also be changes to regulators’ powers and governance arrangements. The changes will also create an entirely new process for handling fitness to practise (the process by which concerns about healthcare professionals are dealt with). The PSA support the reforms to healthcare professional regulation but have also identified certain risks that may arise from the new ways of working. PSA has developed guidance that they are now consulting on. The presentation slides attached are from a recent PSA roundtable and give further information on the changes, PSA guidance and the consultation. PSA are seeking views from everybody with an interest in healthcare professional regulation, including patients, the public, registrants, regulators, professional bodies and employers. The consultation is open until 5.00 pm on Monday 15 April 2024.
  18. News Article
    The BMA has called for an independent inquiry into the use of physician associates (PAs) on medical rotas in place of doctors. The union said that health secretary Victoria Atkins must launch the investigation ‘to get to the bottom of the scale’ of the issue across the NHS, as doctors have been reporting instances where gaps in medical rotas are being filled by PAs. This is happening on top of NHS England ‘investing heavily’ in the use of PAs in primary care, ‘instead of qualified experienced doctors’, the BMA added. On Friday The Telegraph reported on leaked rotas from more than 30 hospitals showing physician associates taking on doctors’ shifts. This coincided with new NHS England guidance to ‘emphasise that PAs are not substitutes for doctors’, as they are ‘supplementary members’ of the team and they ‘should not be used as replacements for doctors on a rota’. BMA chair of council Professor Philip Banfield said: ‘We know from our members’ experiences that hospitals are putting physician assistants on medical rotas, in place of medically qualified doctors. ‘This is on top of NHS England investing heavily in the use of physician associates in primary care, instead of qualified experienced doctors. "In our view, Victoria Atkins now has a duty to patients and a duty to medically qualified staff – doctors – to establish how widespread this practice is and more importantly, stop it." Read full story Source: Pulse, 18 March 2024 Further reading on the hub: Partha Kar: We need a pause to assess safety concerns surrounding Physician Associates
  19. News Article
    A secret report has warned that the NHS is failing to protect trainee paramedics from widespread sexual harassment and racism at work, The Independent has revealed. A confidential NHS England report uncovered by The Independent has found that “extremely alarming” conduct and undermining behaviour are rife in ambulance trusts across the country, with trainees subjected to derogatory comments about their age, ethnicity and appearance in front of patients. There is a “worrying acceptance” that this is “part of the job”, with students hesitant to raise complaints about sexual behaviour by male colleagues in case it gives them a reputation as “annoying snowflakes”, the report says. The revelations come after a recent NHS staff survey revealed that thousands of ambulance staff had reported unwanted sexual behaviour from colleagues and patients last year. One healthcare leader described the findings as “harrowing”, warning that much more needs to be done to protect junior staff. The national report, which is understood to have gone through several edited versions and is marked commercially sensitive, was not due to be released until The Independent obtained the document through a freedom of information request. It found an “undercurrent” of bullying in some areas, with examples of students leaving their jobs as a result of inappropriate behaviour. Trainees reported feeling undervalued and unwanted while on the job, with one apparently told: “Your concerns don’t matter – we have to meet patient demands.” Ambulance handover delays have also led to student paramedics having less experience and training on the job, prompting fears that newly qualified paramedics do not have sufficient levels of experience in life-critical situations. Read full story Source: The Independent, 19 March 2024
  20. Content Article
    Nottingham University Hospitals Trust has produced a leaflet for pregnant people who have experienced vaginal bleeding in later pregnancy. The leaflet aims to give women and families more information about possible causes of bleeding and recommendations that might be made for changes in pregnancy care. The leaflet has been produced in partnership with the parents of baby Quinn Parker, who tragically died in July 2021 after suffering oxygen starvation in the womb.
  21. Content Article
    This episode of the Business of Healthcare podcast delves into the complex and sensitive topic of the mesh scandal which has impacted countless women's lives. Host Tara Humphrey welcomes Consultant Gynecologist and Urogynecology subspecialist Dr Wael Agur to share his expert insights on the rise and fall of mesh devices in surgical procedures. Wael offers a candid look at the multifaceted issues surrounding patient consent, the role of manufacturers, aggressive marketing strategies, and the ethical dilemmas faced by medical professionals.
  22. Content Article
    Imagine an organisational culture of trust, learning and accountability. In the wake of an incident, a restorative just culture asks: ‘who are hurt, what do they need, and whose obligation is it to meet that need?’ It doesn’t dwell on questions of rules and violations and consequences. Instead, it gathers those affected by an incident and collaboratively addresses the harms and needs created by it, in a way that is respectful to all parties. It holds people accountable by looking forward to what must be done to repair, to heal and to prevent. This film documents the amazing transformation in one organisation —Mersey Care, an NHS mental health trust in the UK. Only a few years ago, blame was common and trust was scarce. Dismissals were frequent: caregivers were suspended without a clear idea of what they might have done wrong. Mersey Care’s journey toward a just and learning culture has repaired and reinvigorated relationships between staff, leaders and service users. It has enhanced people’s engagement, joint ownership and sense of responsibility. It has taken the organization to a place where hurt doesn’t get met with more hurt, but with healing.
  23. Content Article
    The Northern Ireland Public Services Ombudsman investigates unresolved complaints about public bodies in Northern Ireland.   Before you make a complaint to us you should normally have: Complained directly to the organisation  Gone through its complaints process Received a final response to your complaint. Their website will give you more information on what Northern Ireland Public Services Ombudsman do, how to make a complaint, and their investigations.
  24. Content Article
    The Health Research Authority, the National Institute for Health and Care Research and a host of organisations across the UK have been working together to bring about changes which will drive up standards in health and social care research. Together they have signed up to a Shared Commitment to public involvement.
  25. News Article
    A controversial unproven medical condition which is rooted in pseudoscience and disputed by doctors is routinely being used in Britain to explain deaths after police restraint, the Observer has found. “Acute behavioural disturbance” (ABD) and “excited delirium” are used to describe people who are agitated or acting bizarrely, usually due to mental illness, drug use or both. Symptoms are said to include insensitivity to pain, aggression, “superhuman” strength and elevated heart rate. Police and other emergency services say the labels, often used interchangeably, are a helpful shorthand used to identify when a person who might need medical help and restraint may be dangerous. But the terms are not recognised by the World Health Organization and have been condemned as “spurious” by campaigners who say they are used to “explain away” the police role in deaths. The American Medical Association rejected “excited delirium” after it was used by police lawyers in the case of George Floyd. California lawmakers banned it as a diagnosis or cause of death in October, saying it had been “used for decades to explain away mysterious deaths of mostly black and brown people in police custody”. The Royal College of Psychiatrists has also warned that the current definition of ABD, as it is now more commonly known in the UK, could be leading to people “being subjected to avoidable and potentially harmful interventions”. In 2017, a Home Office-commissioned review into deaths in police custody said the terms were “strongly disputed amongst medical professionals”. The Royal College of Psychiatrists has also warned that the current definition of ABD, as it is now more commonly known in the UK, could be leading to people “being subjected to avoidable and potentially harmful interventions”. In 2017, a Home Office-commissioned review into deaths in police custody said the terms were “strongly disputed amongst medical professionals”. Read full story Source: The Guardian, 17 March 2024
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