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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    GPs in the UK have some of the highest stress levels and lowest job satisfaction among family doctors, a 10-country survey has found. British GPs suffer from high levels of burnout, have a worse work/life balance and spend less time with patients during appointments than their peers in many other places. Heavy workloads, seemingly endless paperwork and feelings of emotional distress are prompting many GPs to stop seeing patients regularly or even retire altogether, the research found. Seven in 10 (71%) NHS family doctors find their job “extremely” or “very stressful”, the joint-highest number alongside GPs in Germany among the countries analysed. The Health Foundation, which undertook the survey, said its “grim” findings showed that the “unsustainable” pressures on GPs and number of them quitting pose a threat to the NHS’s future.
  2. Content Article
    GPs in the UK are under extreme strain and public satisfaction with general practice has plummeted. Pressures on general practice are not unique to the UK and GPs around the world are contending with the impact of the pandemic on their patients and working lives. The 2022 Commonwealth Fund survey compares perspectives from GPs across 10 high‑income countries. The survey asked GPs’ views about their working lives and wellbeing, quality of care and how services are delivered. The Health Foundation analysed the survey data to understand the experiences of GPs in the UK and how they compare to other countries.
  3. Event
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    Human Factors principles aim to understand the ‘fit’ between an employee, their equipment and the surrounding environment, which can include learning styles, behaviours and values, leadership, teamwork, the design of equipment and processes, communication and organisational culture. In healthcare Human Factors can improve both performance and well-being while improving staff and patient safety. Human Factors has the most significant impact when applied systematically throughout the organisation. The Safety For All campaign is hosting a webinar on the topic of Human Factors and patient safety where attendees will have the opportunity to hear from two experts in the field. An A&E consultant who hosts regular workshops on the importance of Human Factors and how to implement them effectively in healthcare and the Chair of the Clinical Human Factors Group (CHFG), a charity that raises the profile of Human Factors and campaigns for change in the NHS and healthcare. The programme: 12:00 - Welcome by Charlie Bohan-Hurst, Safer Healthcare & Biosafety Network 12:05 - Presentation by Dr Rob Galloway, A&E Consultant: Why human factors is important for healthcare workers 12:50 - Presentation by Professor Chris Frerk, Chair, Clinical Human Factors Group: The role of human factors in delivering safety through design and systems 13:15 - Q&A session 13:25 - Conclusions and wrap up of webinar Register here for free.
  4. News Article
    Thousands of 999 calls are being transferred to the Welsh Ambulance Service because they are taking more than five minutes to answer in England, HSJ can reveal. More than 50,000 calls – 1.2% of all made – were sent to a different ambulance service than the one intended between October and the middle of February, under a new system of routing unanswered calls was introduced. It automatically diverts calls which have not been answered after five minutes, rerouting them to services with current capacity, while a BT operator remains on the line until the call is answered. The Welsh Ambulance Service explained it records details from the transferred caller, prioritises the response level and provides lifesaving instructions if required, including having access to a national database of defibrillators. However, it is unable to despatch ambulances outside its area and does not provide clinical assessment. Instead the details are transferred electronically into the “home” trust’s computer-aided despatch system. Read full story (paywalled) Source: HSJ, 21 March 2023
  5. News Article
    Women at risk of dying in pregnancy or childbirth will be treated at a network of specialist NHS centres under a national drive to halve maternal deaths. For the first time, women in England with conditions such as heart disease, epilepsy or cancer will have access to specialist care from doctors trained to treat medical problems in pregnancy. Two thirds of maternal deaths in the UK are due to medical conditions that pre-date or develop during pregnancy, rather than direct complications of birth. Previously there was no dedicated national service for these women. The 17 NHS centres, covering every region of the country, aim to prevent these deaths by bringing together specialist doctors, obstetricians, midwives and nurses under one roof. GPs and A&E staff will also be trained to identify “red flag” symptoms of illnesses in pregnant women and refer patients directly to the centres, where they can be assessed and receive medication or procedures. Read full story (paywalled) Source: The Times, 20 March 2023
  6. News Article
    Seven British patients who travelled to Turkey for weight loss surgery died after operations there, a BBC investigation into the trend has found. Others have returned home with serious health issues after having had gastric sleeve operations, during which more than 70% of the stomach is removed. The operations, used to treat morbid obesity, are carried out in the UK, but, because it can take years to get one through the NHS, some people are looking abroad for treatment. British doctors say that they're treating an increasing number of patients who have travelled to Turkey and returned with serious complications. Dr Ahmed Ahmed, a leading surgeon and member of council at the British Obesity and Metabolic Surgery Society, says he's treated patients returning from Turkey who have had an entirely different operation to the one they understood they had paid for. The BBC has also been told that some people are being accepted for surgery who do not have a medical need for it. The BBC contacted 27 Turkish clinics to see if they would accept someone for treatment who was considered to have a normal BMI. Six of the clinics we approached were happy to accept someone with a BMI of 24.5 for extreme weight loss surgery. Separately, the BBC also found that some clinics who refused the treatment actually then encouraged patients to put on weight, to enable them to be accepted for surgery. One said: "You need to gain 6.7kg to have sleeve surgery. I think you can easily eat some food and then lose weight easily." Another asked: "How soon can you gain weight?" Dr Ahmed says the practices are "reckless" and "unethical". Read full story Source: BBC News, 21 March 2023
  7. News Article
    Hundreds of patients have lost their eyesight or had it irreparably damaged because of NHS backlogs, new research suggests. NHS England clinicians have filed 551 reports of patients who lost their sight as a result of delayed appointments since 2019, with 219 resulting in “moderate or severe harm”, according to an FoI request by the Association of Optometrists, which believes that hundreds more cases are unreported. Its chief executive, Adam Sampson, said sight loss was a “health emergency”, and urged ministers to introduce a national eye health strategy to enable high street and community optometrists to ease some of the burden on hospitals. He said: “There are good treatments available for common age-related eye conditions like macular degeneration but many hospital trusts simply do not have the capacity to deliver services. “Optometry is ideally placed to take away some of that burden – optometrists are already qualified to provide many of the extended services needed and are available on every high street, so patients can be treated closer to home. It’s incomprehensible and absolutely tragic that patients are waiting, losing their vision, in many parts of the country because of the way eye healthcare is commissioned.” Read full story Source: The Guardian, 21 March 2023
  8. News Article
    Unconscious bias in the UK healthcare system is contributing to the stark racial disparity in maternal healthcare outcomes, a conference has heard. The Black Maternal Health Conference UK, also heard that black women not being listened to by healthcare professionals was also a contributing factor. The conference, organised by The Motherhood Group, was arranged to highlight the racial inequality in maternal healthcare and the disparity in maternal mortality between white, ethnic minority and black women in the UK. Black women in the UK are four times more likely to die in pregnancy and childbirth than white women, according to a report published by MBRRACE-UK. Asian women are twice as likely to die in pregnancy or childbirth. Sandra Igwe, who founded the NGO The Motherhood Group in 2016 after the traumatic birth of her daughter, told the PA Media that the event was an opportunity to “bridge the community, stakeholders, professionals, [and] government”, de-stigmatise mental health and bring about change to improve black maternal health. “There are so many stats – so why wouldn’t we have a whole day’s conference dedicated to addressing these, just scratching the surface of some of the stats?” Charities and activists have been raising alarm bells about the dangerous consequences of unconscious bias in maternal healthcare for many years. Igwe co-chaired the Birthrights inquiry, a year-long investigation into racial injustice in the UK maternity services, which heard testimony from women, birthing people, healthcare professionals and lawyers and concluded that “systemic racism exists in the UK and in public services”. Read full story Source: The Guardian, 20 March 2023 Sandra Igwe is our hub topic lead for Black Maternal Health. Read our recent interview with Sandra.
  9. News Article
    A hospital trust has been told to pay almost a quarter of a million pounds after pleading guilty to failing to provide safe care to a patient with advanced dementia who fatally injured himself. The Care Quality Commission (CQC) brought the prosecution against University Hospitals of Derby and Burton Foundation Trust after an incident in July 2019, when a patient died after absconding from the hospital. Peter Mullis – who had advanced dementia – was admitted to Queen’s Hospital Burton emergency department and absconded twice. When he tried to a third time, he was followed by trust staff. The CQC described how, despite being followed, Mr Mullis was able to climb over a barrier, fall down a grass bank and hit his head on concrete at the bottom. He was airlifted to the local trauma centre, but died of multiple traumatic injuries. The CQC said UHDB did not take “reasonable steps” to ensure safe care was provided and that failure exposed Mr Mullis to “significant risk of avoidable harm”.
  10. Content Article
    Niche Health and Social Care Consulting (Niche) were commissioned by NHS England in November 2019 to undertake an independent investigation into the governance at West Lane Hospital (WLH), Middlesbrough between 2017 up to the hospital closure in 2019. WLH was provided by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and delivered Tier 4 child and adolescent mental health services (CAMHS) inpatient services. This review initially incorporated the care and treatment review findings of two index case events for Christie and Nadia who both died following catastrophic self-ligature at the unit. The Trust subsequently agreed to include the findings of the care and treatment review of Emily which related directly to her time at West Lane Hospital, even though Emily did not die at this site. This is to ensure that optimal learning could be achieved from this review. 
  11. News Article
    Leaders at a mental health trust tolerated high levels of safety incidents and accepted verbal assurance with ‘insufficient professional curiosity’, a critical report has found. An NHS England-commissioned review into governance at Tees, Esk and Wear Valleys Foundation Trust has been published, reviewing the organisation’s response to serious safety concerns flagged at the former West Lane Hospital in Middlesbrough. It follows separate reports identifying “systemic failures” over the deaths of inpatients Christie Harnett, Nadia Sharif and Emily Moore. The new report, conducted by Niche Consulting, criticises board and service leaders’ handling of concerns about the regular occurrence of restraint and self-harm. More than a dozen incidents of inappropriate restraint, some seeing patients dragged along the floor, were identified in November 2018, resulting in multiple staff suspensions and some dismissals. Niche found there was a “lack of accountable leadership at all levels” and lack of evidence for decisions in response to the November 2018 incidents. Read full story (paywalled) Source: HSJ, 21 March 2023
  12. Content Article
    Maria Koijck's goal for this film was to create a movement within the pharmaceutical industry considering the waste it produces. In this film you see Maria lay in the middle of an incredible amount of waste from just one surgery, her surgery. In August 2019 Maria was diagnosed with breast cancer. Surgeons had to remove her entire left breast. After a successful recovery, she went to to have a deep lap surgery where they gave her an entire new breast of her own bodily materials. During this process she discovered that 60% of the surgery materials used for this operation is disposable. For example: the stainless steal scissors that are flown in from Japan, are used for one cut before they end up in the bin. Maria asked the doctors to collect all of the surgery materials used for her operation, to get a clear idea of how much it really was. She was shocked to see six bags full of plastic waste.
  13. Event
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    As one of the largest gatherings of perioperative professionals in the UK, the AfPP Annual Conference is essential for anyone working in the perioperative field. This year’s theme is ‘A Profession To Be Proud Of’. What better way to celebrate this incredible profession than by listening to fantastic speakers, asking exhibitors your burning questions and getting dressed up at our Gala Dinner! Join us at the University of York from 10 – 13 August. If you’re joining us for the entire conference or just for a day, there will be something for everyone. Virtual tickets are also available if you can’t make it to York. Our Annual Conference boasts a full programme of education, networking, hands-on workshops and entertainment. You’ll leave feeling informed, challenged and inspired. If you’re not proud of your profession when you arrive, you will be by the time you leave! Register
  14. Content Article
    In this article, Bevan Brittan Trainee Solicitor Angus Kirkwood draws on his past experience working as a physiotherapist whilst discussing the topic of informed consent in medical practice. Informed consent is a key issue in medical practice. In this article, he briefly consider the law around informed consent and reflects on his previous experience working as a physiotherapist for 7 years to explore the challenges in clinical practice. Angus concludes by providing some practical advice designed to assist practitioners with meeting their legal duties.
  15. News Article
    The pressure to tackle long waiting lists in children’s community services is impacting care quality, clinical leaders have warned. It comes after community health services waiting list figures were published for the first time by NHS England last week. They revealed more than 200,000 children were waiting, of whom 12,000 had been waiting more than a year, and 65,000 more than 18 weeks. While adult community services lists have been coming down fairly steadily since the autumn, children’s services are failing to make progress. The children’s services with the longest lists are community paediatrics (which mostly deals with neurological development issues such as autism and ADHD), speech and language therapy, and children’s occupational therapy. Specialists in those areas told HSJ it was the result of staffing gaps, rising and more complex demand, Covid backlog, and years of underfunding. Read full story (paywalled) Source: HSJ, 20 March 2023
  16. News Article
    The United States remains one of the most dangerous wealthy nations for a woman to give birth. Maternal mortality rose by 40% at the height of the pandemic, according to new data released by the US Centers for Disease Control and Prevention. In 2021, 33 women died out of every 100,000 live births in the US, up from 23.8 in 2020. That rate was more than double for black women, who were nearly three times more likely to die than white women, according to the CDC. Compared to other countries, the maternal mortality rate was twice as high in the US than in the UK, Germany and France; and three times higher than in Spain, Italy, Japan and several other countries, according to the most recent global comparison data kept by the World Bank. "Clearly the US is an outlier," said Joan Costa-i-Font, a professor of health economics at the London School of Economics. "Covid has made [maternal mortality] worse, but it was already a major issue in the US." Read full story Source: BBC News, 18 March 2023
  17. Event
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    Communities are playing an increasingly important role in improving health and meeting the wellbeing needs of people locally, highlighted in part by their role in the response to the Covid-19 pandemic. Integrated care systems (ICSs) need to recognise the role communities can play in improving and sustaining good health, and as part of this they need to seek greater involvement with local voluntary, community and social enterprise (VCSE) groups at the place and neighbourhood level, where the link local communities is at its strongest. This conference will provide an opportunity to discuss the impact of community-led and person-centred approaches to improving health and wellbeing, and to explore what more can be done to build on community interventions, assets and solutions that developed as a response to the pandemic. It will also consider the challenges of demonstrating value and of working with communities to assess need and provide services. You will hear from community groups who have worked with others – including their ICS, local health system or local authority – to develop a collaborative approach to tackling health inequalities.
  18. Event
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    The 2023 Mental Health Network Annual Conference and Exhibition will bring together over 130 senior leaders from the mental health, learning disability and autism sector for lively discussions on the future of services, to share good practice, horizon scan, and network with their peers. The next year brings a range of opportunities and challenges for mental health providers. Organisations are continuing to deliver services whilst facing unprecedented community need, workforce shortages and with the cost of living risking eroding the mental wellbeing of the wider population. Even with these challenges, 2023 presents a year of opportunities. This includes funding secured to continue to deliver the NHS Long Term Plan, a new landscape of integrated care, significant community transformation work underway, and key bills passing through parliament aimed at improving the policy environment mental health providers operate in. The Network’s members will once again come together to focus on the challenges and opportunities the mental health sector faces within the changing context. Register
  19. News Article
    Twenty years ago, David Freedman helped to conduct an audit of the first 124 young people referred to the gender clinic, now he discovers it was never followed up. David Freedman, 73, helped to conduct a clinical audit of the first 124 young people referred to the Gender Identity Development Service (Gids) from its inception in 1989. The London-based service, part of the Tavistock and Portman NHS Foundation Trust, is the only dedicated NHS clinic for transgender children. When he discovered his clinical audit from two decades ago remained the only one conducted by the service, Freedman said he was “gobsmacked”, adding: “This was a service that was sailing into uncharted territory with vulnerable children and adolescents, where one has an extra duty of care, and the failure to collect any data in a coherent form to look at what they were doing . . . it’s pretty mind-boggling.” Read full story (paywalled) Source: The Times, 19 March 2023
  20. News Article
    More than 175,000 patient appointments and surgeries were postponed this week during the three-day junior doctor walk-out, it has emerged. NHS leaders have warned the strikes were the most disruptive yet with more appointments cancelled across three days than across any of the previous nurse strikes. Data published by the NHS showed in total 181,049 patients had their care postponed, this included more than 5,000 mental health and hundreds of community health appointments. The news comes after nursing and ambulance unions accepted a pay offer from the government, for a 5.3 per cent increase in 2023-24, which their members will now vote on. Read full story Source: The Independent, 18 March 2023
  21. News Article
    Women have been left in extreme pain from an invasive procedure that’s been described as the “next big medical scandal”. The Campaign Against Painful Hysteroscopy (CAPH) has collated more than 3000 accounts of “pain, fainting and trauma during outpatient hysteroscopy” throughout the UK – including more than 40 so far from Scotland. CAPH said female patients are being subjected to barbaric levels of pain and claim hospitals prioritise efficiency and cost-cutting over their needs and welfare. The group believes the issue could become as bad as the vaginal mesh scandal, which saw women left in severe pain and with life-changing side effects after being treated with polypropylene mesh implants for stress urinary incontinence and pelvic organ prolapse. Katharine Tylko, of CAPH, said: “Severely painful outpatient hysteroscopy is the next medical scandal after vaginal mesh. Cheap, quick and easy-ish NHS outpatient hysteroscopy without anaesthesia/sedation causes severe pain/distress/trauma to approximately 25 per cent of patients.” Margaret Cannon, from Rutherglen in Lanarkshire, told how she had an “excruciatingly painful” hysteroscopy at Stobhill Hospital in April 2020 without anaesthetic or analgesia. She said: “I am a qualified nurse and midwife, so have good insight into how all the medical and nursing professionals failed me. I had been told to expect mild cramp and I kept thinking, ‘What’s wrong with me that I can’t tolerate the pain?’ I felt violated and assaulted.” She felt so strongly about her experience that she complained. When she finally received a response, she said it “was dismissive and none of my points were addressed”. Read full story Source: Daily Record, 19 March 2023 See also our 'Painful hysteroscopy' thread in the hub Community.
  22. News Article
    Four in 10 NHS hospitals in England are using outdated medical equipment including 37-year-old X-ray machines, according to research from the Lib Dems, who are calling for extra funding to replace outdated devices. NHS hospitals are using hundreds of old X-ray machines, CT scanners and radiotherapy machines, with some dating back to the 1980s, according to research based on freedom of information requests to 69 hospital trusts. Of these, 41 said they had at least one X-ray machine that was more than 20 years old. The Liberal Democrat leader, Ed Davey, said he would call for urgent government investment in medical equipment at the party’s spring conference. “It beggars belief that NHS staff are having to rely on results from decades-old hospital scanners, machinery that may have been built before they were even born. Understaffed and exhausted NHS staff are being pushed to breaking point, while patients are treated in crumbling hospitals with outdated equipment,” he said. “The potential for error from poor-quality machines doesn’t bear thinking about. People up and down the country will be worried about whether they will get an accurate reading from these decades-old machines.” Read full story Source: The Guardian, 20 March 2023
  23. Content Article
    Every day, healthcare professionals face the risk of traumatic events — such as an unexpected death, a medical error, or an unplanned transfer to the ICU. Yet few hospitals have programmes to support “second victims.” Too often, these employees experience self-doubt, burnout and other problems that cause personal anguish and hinder their ability to deliver safe, compassionate care. The Caring for the Caregiver programme from John Hopkins Medicine in the USA guides hospitals to set up peer-responder programmes that deliver “psychological first aid and emotional support” to health care professionals following difficult events. Modelled on the Resilience in Stressful Events (RISE) team at The Johns Hopkins Hospital, the programme prepares employees to provide skilled, nonjudgmental and confidential support to individuals and groups.
  24. Content Article
    The National Patient Safety Board (NPSB) is a proposed independent federal agency modelled in part after the National Transportation Safety Board (NTSB) and Commercial Aviation Safety Team (CAST) that would identify and anticipate significant harm in health care; provide expertise to study the context and causes of harm and solutions; and create solutions to prevent patient safety events from occurring. Watch this video from the Pittsburgh Regional Health Initiative.
  25. Content Article
    Some medical mistakes have been stubbornly hard to eliminate. Now, hospitals hope technology can make a difference. This Washington Post article highlights are some of the biggest problems that caregivers are trying to address with technology.
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