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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
    When surgical site infection (SSI) rates began to climb at University of Wisconsin Health, a multidisciplinary group of surgical professionals assembled to drill down to the root causes of the infections. The Strike Team now has full authority to recommend changes to daily practices and retains final say in what must be done to improve patient care. Learn from the team’s evidence-based success by understanding how they use real-time data to identify gaps in care and implement proven protocols that improve infection prevention practices. Join a live webinar to discover: Evidence based successes in SSI prevention. How to use real-time data to identify gaps in care. Implementation strategies and protocols that improve infection prevention practices. Register
  2. News Article
    New research shared with HSJ has ‘laid bare’ the inequalities experienced by medical trainees, with black doctors more likely to perform worse in exams than any other ethnic group. The report published by the General Medical Council (GMC) highlights that UK medical graduates of black or black British heritage have the lowest specialty exam pass rate of all ethnic groups at 62%, which is almost 20 percentage points lower than that of white doctors (79%). It is the first time the medical regulator has split this data by ethnicity, it said. The GMC has pledged to “eliminate discrimination, disadvantage and unfairness” in undergraduate and postgraduate medical education by 2031 and the disproportionate number of fitness to practise complaints received about ethnic minority doctors and doctors who gained their medical qualification outside of the UK by 2026. Read full story (paywalled) Source: HSJ, 2 March 2023
  3. Content Article
    HTN Now hosted a panel discussion on virtual wards and the future of remote patient care, with guests Tara Donnelly (director of digital care models at NHS England), Sam Jackson (clinical services manager for the Virtual Health Hub at Hampshire Hospitals NHS Foundation Trust) and Jamie Innes (product director at Inhealthcare).
  4. Content Article
    The UK Rare Diseases Framework was published in January 2021 and set out a shared vision for addressing health inequalities and improving the lives of people living with rare diseases across the UK. This is England’s second Rare Diseases Action Plan, following the commitment to publish action plans annually during the lifetime of the UK Rare Diseases Framework. This action plan has been developed in close collaboration with delivery partners across the health system and the rare disease community. It reports on progress against the 16 actions set out in the first Rare Diseases Action Plan and announces 13 new specific, measurable actions for the next year under the framework’s priority areas and underpinning themes.
  5. News Article
    Older and overweight patients are making it harder to clear NHS surgery backlogs, anaesthetists have warned. New data reveal an “extremely worrying picture” of increasing age, rates of obesity and complexity of surgical patients across the UK, the Royal College of Anaesthetists said. The average age of patients requiring anaesthesia increased by 2.3 years, from 50.5 to 52.8, over the last decade, while their BMI also jumped from 24.9 (borderline normal/overweight) to 26.7 (overweight). The proportion of patients who are complex or have other comorbidities has also significantly increased, the study found. When patients are older, overweight and have other problems, this makes anaesthetic and surgical care more complicated and higher risk, the authors said. Managing these patients safely takes longer during surgery and can lead to slower recovery times, requiring more time in hospital. Read full story (paywalled) Source: The Telegraph, 2 March 2023
  6. News Article
    Pharmacies do not have the capacity to absorb pressure from GPs unless it comes with additional funding, pharmacy leaders have warned. A new NHS England ad campaign, announced earlier this week, aims to redirect patients from GP practices to local pharmacies for minor conditions such as coughs, aches, cystitis and colds. But community pharmacy negotiating body PSNC has spoken out against the campaign calling it ‘deeply concerning’, ‘irresponsible, ‘extremely unhelpful’ and ‘irritating’. Malcom Harrison, chief executive of the Company Chemists’ Association (CCA) said: ‘Community pharmacies are often the best place for patient to go for help with minor health concerns. ‘However the current situation that many pharmacies find themselves, with a 30% cut in real term funding, the NHS recruiting their pharmacists and technicians to work in general practice and with the continuing increase in the number of medicines prescribed, will mean that there is now a very real risk that when patients visit a pharmacy, they will be faced by exhausted teams and longer than expected waiting times. ‘The NHS policy of moving asking patients to visit their local pharmacy does not address the problem of delays to access in primary care, it simply moves it from one pressurized location to another. The NHS must address the chronic underfunding of primary care, and of pharmacy in particular, if patients are to be able to access the care they need and should rightly expect.’ Read full story Source: Pulse, 28 February 2023
  7. News Article
    The government must end “age discrimination” against eating disorder patients that is causing avoidable deaths, experts have warned. A cross-party parliamentary group and the Royal College of Psychiatrists are calling for access targets to make sure adults with eating disorders get treated within a set time. The demands come after the healthcare watchdog said patients were dying while waiting to be seen. Wera Hobhouse, chair of the All Party Parliamentary Group, and Agnes Ayton, chair of the Royal College of Psychiatrists’ eating disorder committee, said the targets must be equal to those for children, which were set in 2016. According to the Health Service Journal, 19 patients under the care of inpatient and community eating disorder services have died since 2017. A senior coroner in Norfolk also highlighted failings in 2019 and sent a warning to both NHS England and the Department for Health and Social Care, over the deaths of five young women. Read full story Source: The Independent, 1 March 2023 To support Eating Disorders Awareness Week, we have pulled together eight useful resources to help healthcare professionals, friends and family support people with eating disorders: Top picks: Eight resources on eating disorders
  8. News Article
    A new study has found that the pandemic has severely affected people’s mental health and relationships all over the world, particularly for young adults. The third annual mental state of the world report (MSW) commissioned by Sapien Labs, a non-profit research organisation, conducted a global survey to better understand the state of mental health. The research compiled responses from over 400,000 participants across 64 countries, asking respondents about their family relationships, friendships and overall mental wellbeing. The survey found that there has been little recovery in declining mental health during the pandemic, which the group measures by a score called “mental health quotient”. It had found that average score had declined by 33 points – on a 300-point scale – over the past two years and still showed no signs of recovery, remaining at the same level as 2021. Read full story Source: The Guardian, 1 March 2023
  9. Content Article
    This Mental State of the World report from Sapien Labs provides insight into the mental wellbeing of populations around the globe in 2022 across 64 countries in the Core Anglosphere, continental Europe, Latin America, the Arab world, South and South East Asia and Africa based on responses to the Mental Health Quotient (MHQ) assessment in English, Spanish, French, Arabic, Portuguese (European and Brazilian), German, Swahili and Hindi. The assessment provides an aggregate metric of mental wellbeing (the MHQ) as well as multiple dimensional views.
  10. News Article
    Sam Hindle has 23cm of polypropylene mesh in her body and lives in constant fear that it will become unstable and cause irreversible damage. "You are in your own Battle Royale, strapped to a time bomb, and thinking when is it going to go off," she told the BBC. Sam, 46, is one of hundreds of women in Scotland who have suffered life-changing symptoms since they had a transvaginal mesh implant. After years of campaigning by the women, the Scottish government has promised it will cover the costs of mesh removal at private clinics in the UK and US. But Sam has been waiting more than two years just for a referral to the Complex Mesh Surgical Service in Glasgow to start the process. The Scottish government announced last year that it had signed a contract to allow NHS patients to visit a US expert for mesh removal surgery The contract with Gynaecologic and Reconstructive Surgery of Missouri, where Dr Dionysios Veronikis operates, follows a similar contract agreed with Spire Healthcare in Bristol. The cost of each removal procedure is estimated to be £16,000 to £23,000. But in order to access such treatment, women have to be assessed by the national service in Glasgow. Women like Sam say there are waiting years to just get referred for assessment. With further delays for appointments and then waits for surgery. Read full story Source: BBC News, 2 March 2023
  11. Content Article
    The Clinical Human Factors Group have created a sample template for Trusts looking to recruit a Human Factors and Ergonomics specialist. Please feel free to use and adapt this template to your organisation’s needs.
  12. Content Article
    The Harmed Patients Alliance (HPA) was founded to highlight and promote restorative approaches to healthcare harm. To support their campaign for action, HPA carried out a survey of 44 people asking how those harmed by their contact with healthcare felt about the response, and what impacts this had on them. They were also asked what could have been done differently. 
  13. Content Article
    Slides from the recent Patient Safety Incident Response Framework (PSIRF) governance workshop giving an update and overview from the national team. Presentations were given from the early adopters: Jacquetta Hardacre, Assistant Director Safety and Risk, East Lancashire Hospitals NHS Trust and Kerry Crowther, Patient Safety Specialist, Cornwall Partnership NHS Foundation Trust. The workshop concluded with a Q&A panel with the presenters and Gillian Lewis Head of Patient Safety Strategy Delivery, NHS England.
  14. News Article
    A £14bn plan to reduce NHS backlogs caused by Covid is failing to meet targets, with cancer waiting times at their worst-ever levels, parliament’s spending watchdog has said. A report by the Commons’ public accounts committee said NHS England’s three-year recovery programme for elective and cancer care, agreed in 2022, was already “falling short” in its first year and expressed serious doubts that the wider plan would be achieved on time. MPs found that although the first target was to eliminate two-year waits for elective care by July 2022, there were 2,600 patients who had been waiting more than two years in August 2022, and a record 7 million people on waiting lists in total. The recovery programme was overoptimistic, the report said. “NHS England made unrealistic assumptions about the first year of recovery, including that there would be low levels of Covid-19 and minimal adverse effects from winter pressures.” Read full story Source: The Guardian, 1 March 2023
  15. News Article
    Artificial intelligence could help NHS surgeons perform 300 more transplant operations every year, according to British researchers who have designed a new tool to boost the quality of donor organs. Currently, medical staff must rely on their own assessments of whether an organ may be suitable for transplanting into a patient. It means some organs are picked that ultimately do not prove successful, while others that might be useful can be disregarded. Now experts have developed a pioneering method that uses AI to effectively score potential organs by comparing them to images of tens of thousands of other organs used in transplant operations. The project is being backed by NHS Blood and Transplant (NHSBT), which has almost 7,000 people in the UK on its waiting list for a transplant. “We at NHSBT are extremely committed to making this exciting venture a success,” said Prof Derek Manas, the organ donation and transplantation medical director of NHSBT. “This is an exciting development in technological infrastructure that, once validated, will enable surgeons and transplant clinicians to make more informed decisions about organ usage and help to close the gap between those patients waiting for and those receiving lifesaving organs.” Read full story Source: The Guardian, 1 March 2023
  16. News Article
    A struggling acute trust says its failure to hit its elective care targets is directly linked to doctors’ demanding overtime rates in line with the British Medical Association’s rate cards, as national tensions around the issue intensify. University Hospitals of Morecambe Bay Foundation Trust’s January performance report said its elective activity was down by around 1,000 cases over a two-month period, due to the issue. Last summer, the BMA published a “rate card” outlining the “minimum” hourly pay consultants should receive for additional work, such as waiting list initiatives and weekend shifts. Some accused the union of “acting like football agents” by trying to inflate their members’ pay. NHS chiefs have long been warning of the risk the rate card poses to elective recovery. But there are few examples of a trust making such an explicit link between their struggle to staff overtime shifts because of the rate card and subsequent failure to hit their elective targets, and placing a number on how many patients they were forced to add to the list because of the issue. Read full story (paywalled) Source: HSJ, 1 March 2023
  17. News Article
    Staff endured a “toxic and difficult working environment” at a maternity unit an employment tribunal has found. The tribunal panel said that the case of a black midwife, Kemi Akinmaji, who partially won her case against East Kent Hospitals University Foundation Trust for racial discrimination showed “there were wider issues beyond the specific allegations before us and which were possibly related to race”. The tribunal judgment said: “The evidence we heard reflected a toxic and difficult working environment generally where the claimant and colleagues were shouted and sworn at over differences of professional opinion. There was some evidence before us that there were wider issues beyond the specific allegations before us and which were possibly related to race… “There is evidence of wider bullying of the claimant in the way the group of colleagues treated the claimant… We’ve also heard that the previous grievance had highlighted risks in respect of unconscious bias and identified recommendations which were not actioned. “The race champion was not appointed and the unconscious bias training not sufficiently followed through. We also heard evidence of staff being wary of further such complaints. These matters were all concerning but we had to limit ourselves to the specific allegations brought by the claimant and which the respondent had been given an opportunity to address.” Read full story (paywalled) Source: HSJ, 1 March 2023
  18. News Article
    A trust chief executive has suggested an inquiry team looking at 2,000 deaths is lacking in “expertise” and has created a “disproportionate impression” of the problems at his trust. Essex Partnership University Trust is at the centre of a high-profile inquiry into the deaths of patients over a 20-year period, which was sparked after serious concerns were raised over specific cases. The inquiry, led by Geraldine Strathdee, a former national clinical director for mental health, is reviewing the cases of 2,000 people who died while they were patients on a mental health ward in Essex or within three months of being discharged. In a letter to the inquiry, obtained by HSJ through a freedom of information request, trust chief executive officer Paul Scott wrote: “The headline number of c.1,500 or c.2,000 deaths used in publicity by the inquiry is, in my opinion, not a fair reflection of the deaths that would be of interest to the inquiry.” Read full story (paywalled) Source: HSJ, 1 March 2023
  19. News Article
    A consultant has said that doctors were put under pressure by hospital management not to make a fuss when they raised concerns about nurse Lucy Letby. Dr Ravi Jayaram said his team first raised concerns about unusual episodes involving babies in October 2015 but nothing was done Ms Letby, 33, is accused of murdering seven babies and attempting to murder 10 others at the Countess of Chester Hospital between 2015 and 2016. He told the court the matter was raised again in February 2016 and the hospital's medical director was told at this point. The consultants asked for a meeting but did not hear back for another three months, the court heard. Ms Letby was not removed from front-line nursing until summer 2016. Dr Jayaram told jurors that he wished he had bypassed hospital management and gone to the police. He said: "We were getting a reasonable amount of pressure from senior management at the hospital not to make a fuss." Read full story Source: BBC News, 28 February 2023
  20. News Article
    The National Institute for Health and Care Excellence (NICE) has recommended eight online therapies for anxiety and depression. NICE says the therapies have the potential to help more than 40,000 people in the UK. Each therapy must come with a formal assessment from an NHS therapist in order for it to be recommended. According to NHS Digital, there is a six-week waiting list for patients who need mental health support in England. There are hopes that introducing online digital therapies could ease pressure on the NHS. The treatments can help those with depression, anxiety, PTSD and body dysmorphia and are centred on the use of cognitive behavioural therapy (CBT) - a talking therapy which can help a patient manage their problems by suggesting alterations to their thought process and behaviour. The therapies have been conditionally recommended by NICE - meaning early assessments have taken place to identify promising medical technology but more evidence needs to be gathered. However, Professor Dame Til Wykes, of the School of Mental Health and Psychological Sciences at London's King's College, cautioned "we don't know enough" about the effectiveness of online therapies and whether the therapies will offer sufficient support for mental health patients. Her view was echoed by mental health charity Mind, with content manager Jessica D'Cruz asserting "the majority" of people needing support "will struggle to benefit from this". Read full story Source: BBC News, 1 March 2023
  21. Content Article
    With the NHS often characterised as being trapped in a permacrisis, what can be done to shift the dial? In this NHS Confederation podcast, Daniel Elkeles, chief executive of the London Ambulance Service NHS Trust, talks about improvements in the urgent and emergency care pathway, shifting the narrative on primary care and busting the barriers holding the health and care system back. With industrial action taking a toll, Daniel, who leads the world’s largest ambulance service, sheds light on the untold impact of strikes, the effect on long-term innovation and recovery and why culture change in the ambulance service is top of his mission list.
  22. Content Article
    Victoria Vallance, Director of Secondary and Specialist Care, provides an update on the Care Quality Commission (CQC)’s ongoing national maternity inspection programme and offers early insight into the emerging themes, including good practice examples to support wider learning across all trusts.
  23. Event
    until
    The Healthcare Safety Investigation Branch (HSIB) is facilitating a free half-day event to ask the question on how can healthcare understand and start to manage the risk of staff fatigue. This event is intended to bring together clinical, NHS patient safety representatives and professionals from other safety critical industries. The collaboration of these professionals is intended to share insights around the risk of fatigue, how to consider fatigue in the context of investigations and provide some pragmatic resources and plans for the NHS to introduce the concept and tools for fatigue management. Format The morning of this event is set up for online attendance and along with the team from HSIB, there will representatives from a range of key national healthcare organisations attending the event in person. Speakers will include healthcare professionals, academics, human factors professionals from other industries and healthcare. There will be several short presentations to provide the context and background to the work and activities in the area of fatigue and the risk in healthcare. Speakers will signpost participants to existing resources and information relevant to healthcare organisations. Programme 9.30: Welcome and introductions 9.35 - 9.45 How HSIB has started to consider fatigue in investigations - Dr Laura Pickup, Senior Investigation Science Educator (HSIB). 9.45 - 10.10 Background and scale of fatigue challenge in healthcare - Dr Mike Farquhar, Consultant in Paediatric Sleep Medicine, Guys and St Thomas. 10.10 - 10.35 How does it feel in healthcare - Dr Emma Plunkett, Consultant Anaesthetist in Birmingham and co-chair of the Joint Association of Anaesthetists, Royal College of Anaesthetists and Faculty of Intensive Care Medicine Fatigue Working Group. 10.35 - 10.50 What can we do about fatigue in hospitals - Dr Nancy Redfern, Consultant Anaesthetist Newcastle and co-chair of the Joint Association of Anaesthetists, Royal College of Anaesthetists and Faculty of Intensive Care Medicine Fatigue Working Group 10.50 - 11.05 Coffee Break 11.05 - 11.30 Humans are humans: learning about fatigue investigation and management from two contrasting industries - Mark Young (Railway Safety Investigator RAIB) and Will Tutton (Marine Safety Investigator MAIB). 11.30 - 12.00 Fatigue risk management in practice - Phil Barton, Head of FRMS at EasyJet 12.00 - 12.25 Designing a fatigue risk management system for the NHS: a case study from the UK ambulance sector - Professor Kristy Sanderson (University of East Anglia). 12.25 - 12.30 Closing remarks - Dr Rosie Benneyworth, Chief Investigator, HSIB. Register
  24. Content Article
    This study from Jones et al. identified wide variability in the implementation of the Guardian role and concluded that optimal implementation has six components.
  25. News Article
    A mother-of-one died after a breathing tube was put into her food pipe, despite staff raising concerns it was inserted incorrectly, an inquest heard. Emma Currell, 32, had just received dialysis and was heading home to Hatfield, Hertfordshire, in an ambulance when she had a seizure. An anaesthetic team was called to sedate her as her tongue had swelled and she was bleeding from the mouth. Dr Sabu Syed, who was a trainee anaesthetist, told the hearing: "I used suction to remove blood and I was able to push the tongue to the side and got a partial view." She said she believed she inserted the tube into the trachea - the windpipe - and had asked her senior colleague Dr Prasun Mukherjee to check the position of the tube. "Dr Mukherjee was busy doing other tasks," she added. Technician Nicholas Healey said he flagged his concerns when there was no carbon dioxide reading on the ventilator, which was not faulty. He said that both he and Dr Syed had raised concerns about the tube being in the wrong place. The court heard the hospital had drawn up a guideline checklist for trachea procedures since Ms Currell's death and staff were due to have "no trace = wrong place" training on the warning signs of incorrect insertion. Read full story Source: BBC News, 27 February 2023
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