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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    US health officials say that eyedrops may have killed one person and severely injured several others due to drug-resistant bacterial contamination. The Centers for Disease Control and Prevention (CDC) have identified 68 patients across 16 states with a rare strain of Pseudomonas aeruginosa. The strain had never been found in the US before this latest outbreak. In addition to the one death, eight patients have suffered vision loss, and four have had eyes surgically removed. Most of the patients diagnosed with the infection reported using eyedrops and artificial tears, according to the CDC. Ten different brands were initially identified as possibly linked to the outbreak, the CDC said. Eyedrops that are made in India and imported to the US under two brands were subsequently pulled from shelves in January and February. Read full story Source: BBC News, 17 March 2023
  2. News Article
    The NHS’s efforts to prop up emergency departments with thousands of additional medical staff has been the wrong approach to solving the crisis in these services, experts have argued. Analysis of NHS staffing data by HSJ shows the emergency care medical workforce has grown by almost two-thirds since 2016, far outstripping the growth in other specialties. Despite this, waiting times in accident and emergency have deteriorated significantly over the same period. John Appleby, chief economist at the Nuffield Trust think tank, said: “Cramming the A&E department with more doctors doesn’t look like it’s having the intended effect over the last four to five years. Waiting times have got worse and we have more staff. “Increasing staffing has helped with waiting times in the past, but maybe we have reached a point where it’s not staffing in A&E which is the issue. The issue is the front door and the backdoor of the A&E.” Read full story (paywalled) Source: HSJ, 17 March 2023
  3. Community Post
    Thanks for sharing Sian. We have some resources on the hub from AHRQ on TeamSTEPPS which uses CUS if hub members want to find out more: AHRQ course- TeamSTEPPS® for diagnosis improvement AHRQ - TeamSTEPPS teamwork system AHRQ: TeamSTEPPS® – tools and tactics for good teamwork
  4. Event
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    ELEVATE PX is a gathering bringing together the voices of the global community committed to transforming the human experience in healthcare. ELEVATE PX is a dynamic, interactive event connecting the community for learning, support and the sharing of ideas to positively impact the experience in healthcare organisations around the world. Hear inspiring patient, family and leadership perspectives. All keynotes will be live-streamed for virtual participants. Further information and registration
  5. Event
    Join the British Society for Gynaecological Endoscopy for an endometriosis Q&A session with experts from across the UK. Hosted by Carla Cressy, questions can be put to the panel via the @theBSGE instagram page and the Endometriosis Foundation website. It will cover a wide range of topics from diagnosis to fertility to thoracic and adolescent endometriosis. Register
  6. News Article
    Health Education England (HEE) has outlined a new vision for general practice training which it says will better prepare GPs for future models of care. The programme will have greater focus on areas such as addressing health inequalities and managing the growing proportion of patients with mental health care needs seen in general practice, HEE said. Innovative placements, perhaps with charities, third sector organisations and services such as CAHMS will be explored, the Training the Future GP report said. And it should include educational opportunities around improving cancer detection and referral, the report said, as well as training in the harms of overdiagnosis. Overall the goal is to move to a flexible model of training that meets the needs, skills and experiences of the trainee as well as the area they are working in. HEE said it would also continue to work to address issues of discrimination, prejudice, bias and specifically racism at individual, institutional and systemic levels, and to reduce differential attainment. It will include plans to ensure patients in deprived areas are able to access care, with the development of specific training offers on these issues and prioritising expansion of training capacity to areas in need. Read full story Source: Pulse, 17 March 2023
  7. News Article
    A woman was denied the chance to have children with her husband after a contraceptive coil was accidentally left in place for 29 years. Jayne Huddleston, from Crewe, had eight rounds of fertility treatment she did not need because the correct checks were not carried out by her doctor. She said the mistake happened in 1990. "The GP said it couldn't be seen, so I was sent for a scan and the scan didn't pick anything up, the GP recommended another coil was fitted," she told the BBC. She was told the coil she had fitted around a year earlier had probably fallen out. When she and her husband, David, then decided they wanted to have a child, the second coil was removed, but the first coil, which had gone undetected, remained inside her. They tried for years to have a baby, with no success, including IVF treatment which cost them thousands of pounds. The mistake was only discovered when she went for an X-ray in 2019 after complaining of back pain and the original coil was revealed. Mr and Mrs Huddleston were awarded a six-figure out of court settlement after taking their case to Irwin Mitchell solicitors. Read full story Source: BBC News, 16 March 2023
  8. News Article
    An ambulance trust that was the subject of a documentary involving covert filming by an employee has warned staff they could be subject to ‘disciplinary action and even prosecution’ if they take this type of action. East of England Ambulance Service Trust sent an all staff email yesterday outlining the potential consequences of filming covertly and reminding staff they must adhere to the trust’s social media and digital guidelines. The email, seen by HSJ, followed Channel 4 broadcasting a documentary called Undercover ambulance: NHS Chaos – Dispatches which featured footage filmed covertly by one of the trust’s apprentice emergency technicians, and laid bare the extreme pressures on hospital and ambulance staff. The message sent on Thursday by the trust’s interim officer Melissa Dowdeswell, said the apprentice who carried out the filming had since resigned and then set out what support staff could access from the trust if they had been affected by “an incredibly difficult couple of weeks”. Read full story (paywalled) Source: HSJ, 17 March 2023
  9. Event
    West Hertfordshire Teaching Hospitals NHS Trust Quality Governance team is hosting a series of Patient Safety Learning Summits. Throughout the year they will be holding four events, focusing on patient safety, with a range of speakers (national and international). WHO are the summits aimed for? All healthcare professionals and students who want to learn more about patient safety, participate in the construction of our new patient safety strategy and gain valuable CPD points (30!). WHAT are the summits? They will be international interactive learning conferences where we delve into the transition into Patient Safety Incident Response Framework (PSIRF), in conjunction with discussing the wider patient safety landscape. These summits will include national and international keynote speakers: Prof Matt Inada-Kim- National Clinical Director – infection, antimicrobial resistance & deterioration / CL Covid oximetry @Home / virtual wards Ron Daniels- Founder and Chief Executive, UK Sepsis Trust Helen Hughes- Chief Executive, Patient Safety Learning Paula Reges – infections disease researcher Fiocruz Brazil / advisor to Health Minister Ass Prof Caline Mattar- Global Health and Infectious Diseases at University of Washington, USA Other speakers to include: Médecins Sans Frontières, Red Cross and NHS England WHEN are the summits? There will be four summits throughout the year with overarching themes: Wednesday 26 April- Corporate and Clinical Governance Tuesday 6 June- IPC/AMR/Stewardship Tuesday 5 September – Deteriorating Patients- event aligned to the WHO theme of Engaging Patients Wednesday 10 January 2024- Enhanced Care Needs WHERE are the summits? The events will be held at Watford Football Club and streamed online. British Sign Language interpreters, inductions loops and captions will be present at all events. WHY The trust fully supports the national agenda change to PSIRF and wants to embed the ethos of this framework into everything we do. Patient safety is everybody's business, and everyone has a vital role to play. PSIRF is replacing the Serious Incident Framework and will lead to a culture shift of continuous learning, patient engagement, and a systems-based approach to learning from incidents. The NHS patient safety landscape is evolving, and these summits will give you the understanding, oversight, and passion to be a driver for improvements within your area. Register
  10. Content Article
    A repository of resources aimed at patients and carers which have been co-produced by the Falls and Fragility Fracture Audit Programme (FFFAP) patient and carer panel.
  11. News Article
    Healthgrades recognised 864 US hospitals with its 2023 Patient Safety Excellence Awards and Outstanding Patient Experience Award. Only 83 of those hospitals received both awards. The dual recipients spanned 28 states. Texas had the most dual recipients with 12 honorees — including three Baylor Scott and White Health hospitals. Read full story Source; Becker's Hospital Review, 14 March 2023
  12. News Article
    Deliberate attempts were made to “conceal the extent of racial discrimination” at a national NHS agency, according to a report leaked to HSJ. A highly critical internal report at NHS Blood and Transplant (NHSBT) also said fewer than half the recommendations made in 2020 by external mediation experts, around issues of racism, had so far been actioned. A review conducted by Globis Mediation Group in 2020 found “systemic racism” among management at the agency’s large Colindale site in north London, with ethnic minority staff being “ignored, being viewed as ineligible for promotion and enduring low levels of empathy”. It made nine recommendations, including exploring whether similar issues existed at the other 15 NHSBT sites. Read full story Source: HSJ, 16 March 2023
  13. News Article
    Following the Advanced cyber attack in August 2022, Phil Huggins has revealed to a Digital Health Rewired audience that the NHS has “seen no clinical impact or significant clinical harm”, after a review to be released in the near future. The national chief information security officer for health and care at NHS England was speaking alongside a panel on the Cyber Security Stage on day two of Digital Health Rewired 2023 in London. Huggins explained that although the impact of the Advanced attack was big on the system, in a clinical sense it was not particularly damaging, despite the fact that client data was confirmed to have been exfiltrated. However, Ayesha Rahim, clinical lead for digital mental health at NHS England and chief medical information officer at Surrey and Borders Partnership Foundation Trust, was also on the panel, and spoke of the huge impact the attack had on staff. “The date 4th August is imprinted in my brain”, Rahim said, which is when the attack first happened and was first reported. She explained that it is “quite difficult to fully convey the chaos this caused”, giving examples of staff having no idea what a patient’s background was and therefore having to do everything “blindfolded”. Rahim said staff could not tell if it was safe to go out on visits to mental health patients due to the lack of data and information on them, and every time a person saw a staff member they were retraumatised having to explain their past over and over, including experiences of sexual abuse. Read full story Source: Digital Health, 15 March 2023
  14. Event
    Climate change has been recognised as the “biggest global health threat of the 21st Century”. Healthcare is one of the most significant contributors to greenhouse gas emissions and there are steps which healthcare professionals and organisations can and should be taking to tackle this issue. In 2020, the NHS set out a bold ambition to become the world’s first carbon net zero national health system by 2045. The Safety For All campaign is hosting a webinar on the topic of sustainability where attendees will have the opportunity to hear from a frontline health worker leading the sustainability charge within her NHS trust and the ABHI’s Sustainability Executive who will speak about the steps industry can take to improve sustainability. The webinar is open to everyone with an interest in the importance of sustainability in healthcare. The programme: 13:00 - Welcome by Charlie Bohan-Hurst, Safer Healthcare & Biosafety Network 13:05 - Presentation by Angela Hayes, CNS Palliative & Supportive Care, Clinical Sustainability at The Christie Foundation Trust 13:25 - Presentation by Addie MacGregor, Sustainability Executive at the Association of British HealthTech Industries (ABHI) 13:45 - Q&A session 13:55 - Conclusions and wrap up of webinar. Register for free
  15. Event
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    The provision of safe and quality care is the most fundamental principle to consider for patients in perioperative practice. Alongside this commitment, is the safety and welfare of all staff and visitors within the setting. Risk assessment, staffing ratios, competency and skill are crucial to ensuring that the intended outcome for patients is achieved as far as is reasonably practicable. The discussion will outline how this can be achieved utilising the recommendations by the Association for Perioperative Practice (AfPP). Learning outcomes: Understanding risk and the process of risk assessment in perioperative practice. The components of a safe perioperative environment. How to calculate a safe staffing model for your environment based on the AfPP standard. Register
  16. Event
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    During this seminar you will be joined by Dr Steven Shorrock, Chartered Ergonomist and Human Factors specialist, Dr Lauren Morgan, chartered Human Factors specialist and Dr Neil Spenceley, Clinical Director of Paediatric Intensive Care and Anaesthesia, Royal Children’s Hospital, Glasgow. Dr Steven Shorrock - Understanding and improving the reality of human work Learning from everyday work should be the aim of all efforts to improve organisational functioning and performance. The reality of 'work-as-done’ (how things really get done) by everyone, in front-line, support, and management roles, influences all aspects of organisational functioning. This session will explore and demystify some key themes and myths: The realities of work at all levels. Understanding work-as-done and its proxies. Improving how we work. Dr Lauren Morgan - Building Human Factors into the fabric of our hospitals The design of healthcare environments can significantly influence clinical outcomes, efficiency, staff wellbeing and retention. Healthcare providers and employers who take steps to understand the reality of working practice (work-as-done) soon see the practical benefits to inclusive design. In this session Lauren shares some of the human factors approaches she uses in including staff and patients in designing hospitals and clinical areas. Register
  17. Content Article
    In a series of blogs for the hub, we will be highlighting the impact fatigue has on staff and patients. In their first blog, Emma Plunkett and Nancy Redfern, part of the Joint Working Group on Fatigue, shared how they became involved in investigating night shift fatigue, setting up the Joint Working Group on Fatigue and the aims of the #FightFatigue campaign. In this second blog, Emma and Nancy are joined by Roopa McCrossan to highlight how tiredness can impact on our performance, the patient and staff implications of fatigue, and the actions that need to be taken not only at an organisational level to improve culture, but the effort required at national level too.
  18. News Article
    Some hospitals are suspending supplies of gas and air, after it was found to pose health risks to midwives. What can be done to ensure pregnant women still get the help they need? When Leigh Milner was expecting her first baby, she knew exactly how she wanted her labour to go. Her birth plan included an epidural for the pain and she was hoping, she says ruefully, for “all the drugs”. But that is not how things worked out. Milner, 33, a BBC presenter, ended up giving birth to Theo at Princess Alexandra hospital in Harlow last month with nothing but paracetamol for pain relief, in what she calls a positively “Victorian” experience. “I kept begging over and over again – ‘I need something for pain relief’ – and the only thing they could give me was paracetamol because they didn’t have gas and air. I was quite frightened, I didn’t know what else to do,” says Milner. "Birth is painful, but it shouldn’t be traumatic.” Read full story Source: The Guardian, 16 March 2023
  19. News Article
    Gonorrhoea cases in England have resurged since the easing of Covid restrictions, health officials are warning people who are sexually active. The disease is caused by the bacterium Neisseria gonorrhoeae. The infection is spread by unprotected vaginal, oral and anal sex. Symptoms can include a thick green or yellow discharge from sexual organs, pain when urinating and bleeding between periods, but some people will have no symptoms. Condoms can stop the spread of this and other sexually transmitted infections. Experts say people should practise safe sex and get tested regularly if they are having sex with new or casual partners. Testing is simple, free and discreet, they advise. Provisional data shows diagnoses in the first half of 2022 hit 56,327 - 21% higher than for the same period in 2019. An untreated infection can lead to infertility, pelvic inflammatory disease and can be passed on to a child during pregnancy. Read full story Source: BBC News, 16 March 2023
  20. News Article
    Life expectancy in the UK has grown at a slower rate than comparable countries over the past seven decades, according to researchers, who say this is the result of widening inequality. The UK lags behind all other countries in the group of G7 advanced economies except the US, according to a new analysis of global life expectancy rankings published in the Journal of the Royal Society of Medicine. While life expectancy has increased in absolute terms, similar countries have experienced larger increases, they wrote. In the 1950s, the UK had one of the longest life expectancies in the world, ranking seventh globally behind countries such as Denmark, Norway and Sweden, but in 2021 the UK was ranked 29th. The researchers said this was partly due to income inequality, which rose considerably in the UK during and after the 1980s. Prof Martin McKee, of the London School of Hygiene & Tropical Medicine, said: “That rise also saw an increase in the variation in life expectancy between different social groups. One reason why the overall increase in life expectancy has been so sluggish in the UK is that in recent years it has fallen for poorer groups". Read full story Source: The Guardian, 16 March 2023
  21. Content Article
     Researchers writing in the Journal of the Royal Society of Medicine say that while UK life expectancy has increased in absolute terms over recent decades, other, similar countries are experiencing larger increases. In 1952, when Queen Elizabeth II came to the throne, the UK had one of the longest life expectancies in the world, ranking seventh globally behind countries such as Norway, Sweden and Denmark. In 2021 the UK was ranked 29th. The researchers show the rankings of the G7 countries at each decade from 1950 to 2020. The G7 is a collection of countries with advanced economies (UK, Canada, France, Germany, Italy, Japan and the U.S.) that represent about half of global economic output.
  22. News Article
    NHS staff have accused Steve Barclay of breaking a pledge to publish details of how many of them are abused and assaulted in the course of their work. In 2018, when Barclay was a junior minister in the Department of Health and Social Care (DHSC), he promised he would resume publication of those statistics in the following year. However, five years later, Barclay has not fulfilled his pledge, despite being in his second stint as health secretary. Health unions and NHS leaders have warned that frontline staff have been on the receiving end of increased abuse, threats, aggression and assaults since the first outbreak of Covid. Long waiting times for care appear to be a particular source of frustration for some patients or their relatives. Growing numbers of ambulance crew personnel have begun using body-worn cameras in recent years to deter assaults and record any that do occur. In 2022, the London ambulance service recorded 877 reports of verbal abuse or threats of violence, 516 physical assaults – including kicking, punching, head-butting and use of a weapon – and 49 sexual assaults on staff. Read full story Source: The Guardian, 16 March 2023
  23. News Article
    The disruption caused by the junior doctors' strike in England could take weeks to resolve, health bosses say. Tens of thousands of appointments and treatments, including cancer care, had to be cancelled during the three-day walkout. Patients with appointments coming up may see them cancelled to make room for high-priority cases hit by the strike. Hospitals are also reporting problems discharging patients from wards, as consultants were sent to cover A&E. Saffron Cordery, of NHS Providers, which represents NHS trusts, said the scale and length of the walkout, coupled with the fact it started on a Monday - traditionally the busiest day of the week - had made it more difficult than previous strikes by nurses and ambulance staff. "It will take weeks to recover - just rebooking patients who have treatments and appointments cancelled is a big job," she said. "Patients have to be individually prioritised - it may mean some patients with bookings in the coming weeks being pushed further back." Read full story Source: BBC News, 16 March 2023
  24. News Article
    A chief executive has apologised after a survey of his trust’s staff from minority ethnic backgrounds found many had been subjected to racist behaviour by colleagues. The staff at East of England Ambulance Service Trust said peers had made monkey noises and referred to banana boats in front of them, excluded them from social events, and assumed they could speak Middle Eastern and Asian languages just because of their skin colour, they told researchers. The trust has had substantial cultural problems for several years, and commissioned the survey to “better understand the experience, perceptions and realities of the trust BME staff”, a board paper said. The report on its findings, published this week in trust board papers, warns: “There are risks that a minority of EEAST employees are demonstrating behaviours or using language which could be perceived as racist. Reports of subsequent inaction by managers further risk this behaviour being normalised.” Read full story (paywalled) Source: HSJ, 15 March 2023
  25. News Article
    The US Emergency Care Research Institute (ECRI) has said the paediatric mental health crisis is the most pressing patient safety concern in 2023. ECRI, which conducts independent medical device evaluations, annually compiles scientific literature and patient safety events, concerns reported to or investigated by the organization, and other data sources to create its top 10 list. Here are the 10 patient safety concerns for 2023, according to the report: 1. The pediatric mental health crisis 2. Physical and verbal violence against healthcare staff 3. Clinician needs in times of uncertainty surrounding maternal-fetal medicine 4. Impact on clinicians expected to work outside their scope of practice and competencies 5. Delayed identification and treatment of sepsis 6. Consequences of poor care coordination for patients with complex medical conditions 7. Risks of not looking beyond the "five rights" to achieve medication safety 8. Medication errors resulting from inaccurate patient medication lists 9. Accidental administration of neuromuscular blocking agents 10. Preventable harm due to omitted care or treatment For the number one spot, ECRI said the COVID-19 pandemic raised the situation, which includes high rates of depression and anxiety among children, to crisis levels. ECRI President and CEO Marcus Schabacker, MD, PhD, said social media, gun violence and other socioeconomic factors were fueling the issue, but COVID-19 pushed it into a crisis. "We're approaching a national public health emergency," Dr. Schabacker said in a statement. Read full story Source: Becker's Hospital Review, 13 March 2023
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