Jump to content
 View Profile  See their activity

  • Posts

    11,589

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

Everything posted by Patient Safety Learning

  1. News Article
    Repeated cases of bullying and a toxic environment at one of England's largest NHS trusts have been found in a review. The Bewick report was ordered after a BBC Newsnight investigation heard from staff at University Hospitals Birmingham (UHB) saying a climate of fear had put patients at risk. A first phase of the rapid review, headed by independent consultants IQ4U and led by Prof Mike Bewick, was published Tuesday. It is one of three major reviews into the trust, commissioned following a series of reports by Newsnight and BBC West Midlands in which current and former staff raised concerns. Summarising the findings, Prof Bewick, a former NHS England deputy medical director, said: "Our overall view is that the trust is a safe place to receive care. "But any continuance of a culture that is corrosively affecting morale and in particular threatens long-term staff recruitment and retention will put at risk the care of patients across the organisation - particularly in the current nationwide NHS staffing crisis. "Because these concerns cover such a wide range of issues, from management organisation through to leadership and confidence, we believe there is much more work to be done in the next phases of review to assist the trust on its journey to recovery." The West Midlands trust said it fully accepted the report's recommendations. Read full story Source: BBC News, 28 March 2023
  2. News Article
    “There’s a gap today that no locum filled, so I am carrying both bleeps and doing the work of two people.” That recent tweet, by a children’s doctor, is one of many examples posted on social media by medics illustrating how NHS staff shortages affect them, patients, the smooth running of important services – and, sometimes, the safety of those who are receiving care. It is a concern shared by every organisation that represents frontline staff, by regulators such as the Care Quality Commission (CQC), and by NHS England, the body that oversees the service. In January the CQC reported that an inspection it had undertaken of Colchester hospital in Essex found patients were missing out on meals because there were too few staff on duty to feed them. Some patients were wearing dirty dressings, and others did not have their call bells answered promptly, for the same reason. In a letter to the trust that runs the hospital, it said: “All wards’ actual staffing levels and skill mix meant staff were often overstretched. All staff we spoke with expressed concern about the impact on patient care and personal wellbeing. “Some staff we spoke to were tearful, reported feeling exhausted and concerned that they were unable to care for patients well enough to keep them safe.” Read full story Source: The Guardian, 26 March 2023
  3. News Article
    Hospices will be forced to turn dying patients away because they are struggling with steeply rising costs at a time when the NHS is not increasing funding. Hospices look after 300,000 patients and families every year across the UK. It costs about £1.5 billion a year for them to provide this care, with only a third of that coming from the NHS. The rest relies on charitable donations and fundraising in local communities as well as sales in charity shops. As hospices battle to keep going, the Treasury has rejected pleas for a £30 million rescue package this year. The money, those in the sector say, would prevent some from having to close inpatient units and beds or reduce their hospice-at-home teams, which care for patients in the community. Some are already making staff redundant and getting rid of beds. Toby Porter, chief executive of Hospice UK, said the government was making “a huge avoidable mistake”, adding: “People will have a lesser experience at an incredibly important moment and it will lead to system pressures affecting the whole health system.” Read full story (paywalled) Source: The Times, 26 March 2023
  4. News Article
    Last year the World Health Organization (WHO) released a report warning of a “ticking time bomb” threatening health systems in Europe and Central Asia: a growing shortage of health workers. With quickly ageing populations and an ageing health workforce—40% of doctors in Europe are close to retirement in a third of countries—along with a surge in chronic illnesses and the ongoing effects of the covid pandemic, WHO warned that many countries could soon see their healthcare systems collapse unless they take urgent action. Six months on, the situation has worsened, as healthcare workers throughout Europe increasingly resort to industrial action over pay and conditions. Hans Kluge, WHO regional director for Europe, said, “The health workforce crisis in Europe is no longer a looming threat—it is here and now. Health providers and workers across our region are clamouring for help and support... “We cannot wait any longer to address the pressing challenges facing our health workforce. The health and wellbeing of our societies are at stake—there is simply no time to lose.” Read full story (paywalled) Source: BMJ, 24 March 2023
  5. Content Article
    From April 2023, the Care Quality Commission (CQC) will have power to assess integrated care systems, implementing a phased approach to develop the necessary competencies and relationships needed to assess these complex systems. This briefing summarises the interim guidance on the CQC's approach, and shares the NHS Confederation's analysis and viewpoint.
  6. Content Article
    Can you imagine the distress of going to hospital for an operation and having to return to theatre to have forceps removed because they were left inside your abdomen. Or going in for a left hip operation because of years of agonising pain and waking up to find out they had operated on your good hip. Or having surgery to preserve your ovaries — but they are accidentally removed. Or, worst of all, realising you have had a procedure intended for a different patient. Fanciful stories made up for a TV drama? Sadly not. These were just some of the awful mishaps that occurred in hospitals in England over the space of just ten months. Professor Rob Galloway, writing for the Daily Mail, shares his tips on what patients can you do to protect themselves.
  7. Event
    Baby Lifeline has announced that their fourth annual National Maternity Safety Conference will take place on Thursday 21st September 2023 at the Hilton Metropole Hotel in Birmingham. Once again it will be focussing on learning together for a safer maternity future, building on the overwhelming success of the previous three conferences. Baby Lifeline is always keen to showcase best practice in healthcare and are pleased to welcome poster presentation abstracts again this year. They are particularly keen to hear about maternity service quality improvement measures which speak to one or more of the following themes: Listening to families and staff Promoting safety culture Teamworking Reducing mortality & morbidity. Register
  8. News Article
    Dilshad Sultana was 36 weeks pregnant with her second child in 2019 when she experienced stomach pain and noticed her baby was moving less. Mrs Sultana, from Sutton Coldfield, said she had been due to have a Caesarean section on 8 July but on 20 June she started to feel pain in her abdomen and lower back. She said she was confused but that it did not feel like a contraction and called hospital staff at about 17:00 to say it felt like her baby was moving less. After following advice to rest and take pain relief, she attended hospital at about 22:30 and staff started monitoring Shanto's heart rate. It was not until almost three hours later that Shanto was delivered by emergency C-Section. Shanto suffered severe brain damage and would spent the next 22 days in intensive care, suffering seizures and multiple brain haemorrhages. Shanto now requires around-the-clock care and Mrs Sultana enlisted lawyers to pursue a care of medical negligence against the trust. Birmingham Women's and Children's NHS Foundation Trust has admitted liability and made a voluntary interim payment allowing the family to move to a new home specifically adapted to meet Shanto's extensive care, therapy and equipment needs. Fiona Reynolds, the chief medical officer, said: "We'd like to offer our heartfelt apologies again to the family. "It's clear the standard of care we offered to them fell below those required and expected. For this, we are truly sorry." Now, Mrs Sultana is campaigning for change - she wants to see mothers listened to in maternity care and more attention paid to monitoring babies' heart rates. Read full story Source: BBC News, 27 March 2023
  9. News Article
    Two external reviews have been carried out into a trust’s general surgery services amid concerns about whether it is a ‘safe interpersonal working environment’. But University Hospitals Sussex Foundation Trust has refused to make the reviews – which were both completed last year – public, partly because of what it says are concerns that they could lead to “harassment” of doctors who spoke to the authors. Both reviews were into aspects of the general surgery services at the Royal Sussex County Hospitals in Brighton. The trust has had a series of highly critical Care Quality Commission reports into some of its surgical services and a “well led” report is expected to be released in the next few weeks. The trust has refused HSJ’s Freedom of Information Act request to release the reviews, arguing that those interviewed had been promised confidentiality, and the issues involved are “emotive and sensitive matters”. “Disclosure could cause those involved in the reviews damage, distress and upset and could even lead to harassment,” it said. Read full story Source: HSJ, 27 March 2023
  10. News Article
    A woman whose daughter took her own life after being left in chronic pain caused by giving birth has spoken of her family's heartbreak. Sara Baines, 34, from Flintshire, died in September last year leaving her family devastated. This week an inquest heard Sara suffered from chronic pain due to complications resulting from surgical mesh that was implanted after she gave birth in 2011. Her mother, Alison Sharrock, says Sara was failed by the health system on multiple occasions. Sara bled heavily whilst giving birth and suffered a second-degree tear. She had to have two surgeries to repair the tear, neither of which was completely successful. Sara found herself completely incontinent, at the age of 24. In 2015, Sara was advised to have mesh fitted. Alison said: "We were told the mesh was a 'quick-fix'. It felt like the answer to all her problems and she was thrilled. She had surgery but afterwards, though the incontinence improved, she had terrible abdominal pain." The pain became so severe that Sara was offered a hysterectomy, aged 28. Afterwards, the pain only intensified, and her general health deteriorated. She suffered water infections, skin rashes, gum disease and unexplained pain. Unable to eat or sleep, she became depressed and anxious. "She felt nobody was really listening to her. She felt she was gaslighted and fobbed off," said Alison. Kath Sansom, founder of Sling The Mesh which has almost 10,000 members suffering irreversible pan and complications from surgical mesh implants, said: "Our hearts go out to Sara's family. Nine out of 10 people in our support group were not told any risks of having a plastic mesh permanently implanted." Read full story Source: Mail Online, 24 March 2023 Further reading on the hub: Doctors’ shocking comments reveal institutional misogyny towards women harmed by pelvic mesh “There’s no problem with the mesh”: A personal account of the struggle to get vaginal mesh removal surgery ‘Mesh removal surgery is a postcode lottery’ - patients harmed by surgical mesh need accessible, consistent treatment
  11. News Article
    Whistleblowers have described the accident and emergency (A&E) department at Hull Royal Infirmary as "incredibly dangerous" and a "death trap". The Care Quality Commission (CSC) found Hull University Teaching Hospitals required improvement overall and its A&E department was rated inadequate. Two clinical staff members, who wished to remain anonymous, described it as a "toxic" place to work. Speaking to the BBC, the two staff members who have worked in Hull's A&E department said they had raised concerns with senior managers and the CQC. They said there were frequently fewer staff than needed and warned inexperienced staff, one whom had never seen a cardiac arrest, were working in areas like resuscitation, which was "incredibly dangerous". "Nurses who aren't even signed off to give oral medication are being put in resuscitation," one said. "It's a death trap, it is terrifying." Despite these concerns, CQC inspectors in December and November did find the service "had enough nursing and support staff to keep patients safe". Read full story Source: BBC News, 28 March 2023
  12. News Article
    The NHS in England needs a massive injection of homegrown doctors, nurses, GPs and dentists to avert a recruitment crisis that could leave it short of 571,000 staff, according to an internal document seen by the Guardian. A long-awaited workforce plan produced by NHS England says the health service is already operating with 154,000 fewer full-time staff than it needs, and that number could balloon to 571,000 staff by 2036 on current trends. The 107-page blueprint, which is being examined by ministers, sets out detailed proposals to end the understaffing that has plagued the health service for years. It says that without radical action, the NHS in England will have 28,000 fewer GPs, 44,000 fewer community nurses and an even greater lack of paramedics within 15 years. However, the Guardian understands that the chancellor, Jeremy Hunt, is playing a key role in behind-the-scenes moves by the Treasury to water down NHS England’s proposals to double the number of doctors that the UK trains and increase the number of new nurses trained every year by 77% – because it would cost several billion pounds to do that. A senior NHS leader said: “Jeremy Hunt has been very resistant to the numbers in the workforce plan. The Treasury and Hunt don’t want numbers in it. They want it to be not very precise. They want the numbers to be projected in a different way that would be less expensive and to not commit to training specific numbers of doctors, nurses and others. “While intellectually Hunt gets it, and emotionally he gets the patient safety argument, it seems that his priority, if the government has any financial headroom, is to use that for tax cuts or giving the army more money rather than training more doctors, nurses and speech and language therapists. Read full story Source: The Guardian, 26 March 2023
  13. Content Article
    This is Patient Safety Learning’s submission to the consultation on the Professional Standards Authority (PSA) draft strategic plan 2023-26. The PSA were seeking the views of patients, service users, regulators, Accredited Registers and other stakeholders on the work that they do, how they work and how their strategic plan can help them to have a meaningful impact on patient and service user safety and public protection. The consultation is now closed.
  14. News Article
    A son has accepted a settlement and an apology from the north Wales health board nearly 10 years after his mother was a patient in a mental health unit. Jean Graves spent nine weeks at the Hergest unit in Ysbyty Gwynedd in Bangor in 2013 after struggling with anxiety and depression. Her son David said she was left "severely malnourished" and fell. He previously said his mother - who was 78 when she was treated at the unit - collapsed six times and, over the course of six weeks, lost 25% of her body mass. The health board also apologised for the "distress" the family experienced while seeking answers "over many years" and said it hopes to "learn and improve" from Mr Graves's experience. In a letter to him, executives said: "It is very clear to us that we have failed your mother and that she should have had a better care whilst in our services." It said her records were incomplete or were "amended without proper evidence" and she was placed on a ward with a mix of patients with both psychiatric illness and older organic mental illness, which was not "best practice". Read full story Source: BBC News, 26 March 2023
  15. News Article
    A young woman receiving end-of-life care says she is “just waiting to die” as an agonising three-year wait for a kidney transplant has left her “living like a prisoner”. Diana Isajeva is one of approximately 7,000 patients who are on the waiting list, according to the NHS Blood and Transplant service (NHSBT) – the highest figure in a decade. The 29-year-old was due to have a transplant last year but was denied it at the last minute, after the living donor she was matched with pulled out just 24 hours before her planned surgery. Data from NHSBT shows that the rate of families giving consent for their loved ones’ organs to be donated has dropped – despite a change in the law in 2020 aimed at boosting the number of organs available, which means that consent for donation is now presumed after death. Professor Peter Friend, transplant lead for the Royal College of Surgeons (RCS), said decreasing donor rates are a “big challenge” and that it is concerning that the number of donations has not yet recovered to its pre-pandemic level. Read full story Source: The Independent, 27 March 2023
  16. News Article
    The high-profile Australian neurosurgeon Charlie Teo admits making an error by going “too far” and damaging a patient, but maintains she was told of the risks. The doctor on Monday appeared at a medical disciplinary hearing to explain how two women patients ended up with catastrophic brain injuries. Teo also defended allegations that he acted inappropriately by slapping a patient in an attempt to rouse her after surgery, contrasting it with Will Smith’s notorious slap of Chris Rock at the Academy Awards last year. “It wakes them up and it wakes them up pretty quickly. And I will continue to do it.” Charlie Teo tells inquiry he ‘did the wrong thing’ in surgery that left patient in vegetative state One of the issues the panel of legal and medical experts is considering is whether the women and their families were adequately informed of the risks of surgery. Both women had terminal brain tumours and had been given from weeks to months to live. They were left in essentially vegetative states after the surgeries and died soon after. “We were told he could give us more time,” one of the husbands said, according to court documents. “There was never any information about not coming out of it". Read full story Source: The Guardian, 27 March 2023
  17. News Article
    UK ministers should act to ensure Long Covid sufferers receive the support they need from employers, with as many as two-thirds claiming they have been unfairly treated at work, a report argues. The report, from the TUC and the charity Long Covid Support, warns that failing to accommodate the 2m people who, according to ONS data, may be suffering from long Covid in the UK will create, “new, long-lasting inequalities”. The analysis is based on responses from more than 3,000 long Covid sufferers who agreed to share their experiences. Two-thirds said they had experienced some form of unfair treatment at work, ranging from harassment to being disbelieved about their symptoms or threatened with disciplinary action. One in seven said they had lost their job. The report makes a series of recommendations, including urging the government to designate Long Covid as a disability for the purposes of the 2010 Equality Act, to make clear sufferers are entitled to “reasonable adjustments” at work; and to classify Covid-19 as an occupational disease to allow people who contracted it through their job to seek compensation. Read full story Source: The Guardian, 27 March 2023
  18. Content Article
    The Covid-19 pandemic continues to impact heavily on all our lives and one of the long-lasting, but unanticipated, impacts is the emergence of Long Covid. Whilst many people infected by Covid-19 may fully recover, significant numbers will experience varied, ongoing and debilitating symptoms that last weeks, months or years following the initial infection. This prolonged condition has been given the umbrella term Long Covid. Recognition of Long Covid was accelerated by people-led advocacy groups such Long Covid Support. The Office of National Statistics (ONS) reported that, as of 1 August 2021, 970,000 people in the UK were experiencing self-reported Long Covid. The most recent data from 2 January 2023, shows that this has increased to 2 million people This report summarises the findings of a self-selecting survey of 3,097 people with Long Covid in September and October 2022 on their experiences of work.
  19. News Article
    Plans for integrated care systems (ICSs) to be given Care Quality Commission (CQC) ratings are on hold, and no ratings will be issued until summer 2024 at the earliest, HSJ understands. The government had previously said ICSs would be given ratings – after pressure from Jeremy Hunt, then Commons health committee chair and now chancellor – and there was an expectation the process would begin next month. However, while legislation says the CQC will review and assess ICSs, it does not require it to give ratings. HSJ understands the Department of Health and Social Care supports the CQC beginning early work on assessing ICSs shortly, but does not plan to sign off on ratings being issued, nor set any date for that to happen. It means that, at the very earliest, more detailed reviews leading to ratings could happen from spring/summer 2024. One source with knowledge of the decision said there was not strong support for ratings work to start, and the CQC still needed to do a lot of work to adapt its approach to ICSs. Read full story (paywalled) Source: HSJ, 27 March 2023
  20. Content Article
    Healthcare IT News interviewed Wendy Deibert, senior vice president of clinical solutions at Caregility, a telehealth technology and services company, to talk about virtual nursing's role in helping tackle the nursing shortage.
  21. News Article
    US clinical and nonclinical healthcare workers have an upward-trending perception of safety culture, but physicians and leaders do not agree, according to a Press Ganey report. Press Ganey, a US company that focuses on patient satisfaction surveys, found in its annual safety culture trends report that senior management perceptions of all safety culture metrics are lower. Overall safety scores are down 0.04 points, prevention and reporting decreased 0.02 points, pride and reputation declined 0.05 points, and resources and teamwork are down 0.04 points. The report analysed 2022 data from 813,900 healthcare workers across 194 systems and 3,279 facilities. "Senior management safety culture scores are typically higher than those of operational management, suggesting a more positive perspective among those at the highest levels of provider organizations," the report said. "Yet the continued downward trajectory of senior management scores stands out as significant." Among physicians, pride and reputation fell 0.12 points. Their perceptions of overall safety declined 0.06 points, prevention and reporting is down 0.03 points, and resources and teamwork is down 0.05 points. Other healthcare employees had higher perceptions of these metrics except for pride and reputation. Also, "fewer employees today say they would recommend their organization for care than in previous years," Press Ganey found. Read full story Source: Becker's Hospital Review, 21 March 2023
  22. Event
    until
    What we are witnessing across the NHS is the Mid Staffs scandal playing out at national level, if not worse. At the beginning of 2023, Sir Robert Francis and Rachel Power, Chief Executive of the Patients Association, set out their concerns about the ‘disaster unfolding in the NHS’ in a letter to the Secretary of State for Heath and Social Care. With the NHS currently focusing on productivity, despite staff burnout and workforce shortages; operational performance, despite the growing backlog; and financial control, despite significant financial restraints, how can the NHS ensure quality across its services? 10 years on from Sir Robert Francis’ inquiry into the failings in care at Mid Staffordshire NHS Foundation Trust and in the context of the Covid-19 pandemic, workforce shortages and significant financial restraints, this event will explore what quality looks like to service users, and how staff and organisations can deliver quality care during periods of extreme pressure and demand. Register
  23. Content Article
    In this study, Tsampasian et al. looked at what the risk factors were for developing post−COVID-19 condition (also known as Long Covid). The systematic review and meta-analysis of 41 studies, including 860 783 patients, found that female sex, older age, higher body mass index, smoking, preexisting comorbidities, and previous hospitalisation or ICU admission were risk factors significantly associated with developing Long Covid, and that SARS-CoV-2 vaccination with two doses was associated with lower risk of Long Covid. The findings of this systematic review and meta-analysis provide a profile of the characteristics associated with increased risk of developing Long Covid and suggest that vaccination may be protective against Long Covid.
  24. Event
    until
    About 900,000 Americans develop venous thromboembolisms each year, about half of which are healthcare-associated. Up to 70% of these blood clots are preventable, yet fewer than 50% of hospital patients receive appropriate preventive treatment, according to the CDC. During this webinar, two experts will share tools and strategies nursing leaders can use to empower their teams to become VTE prevention champions and achieve sustained quality improvements. Learning points: The cost of VTEs — from patients to providers to financial repercussions Key strategies to enhance compliance and improve outcome quality How to energize and excite your team for long-term success. Register
  25. News Article
    The UK is supposed to have one of the best systems in the world for preventing vulnerable people being exploited for their organs. How then did one of its biggest hospitals become embroiled in the macabre trade of kidney harvesting? The UK’s first trial organ trafficking trial has exposed alarming vulnerabilities to a illegal trade that makes up 10% of transplants worldwide. The case has highlighted how poverty can tempt some people to sell their body parts to those willing to exploit an acute global shortage of organs for donation. The case heard that doctors at a private renal unit at London’s Royal Free hospital and the regulators, the Human Tissue Authority (HTA), were fooled by Dr Obinna Obeta, into approving his kidney transplant in July 2021. As the prosecutor, Hugh Davies, said: “If there’s a lesson to be learned here – those clinicians need to set the index of suspicion for safeguarding somewhat lower.” Dominique Martin, a professor of health ethics at Australia’s Deakin University who studies organ trafficking, said the case highlighted the need for robust vetting by hospitals and regulators. She said: “There is a level of complacency, including in the UK, the US and Australia regarding the risks of organ trafficking happening within our borders. Screening programmes may not be as strong as we assume or as consistently implemented as we might expect.” Read full story Source: The Guardian, 23 March 2023
×
×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.

 Accept Cookies  Reject Cookies