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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    A cross-border trial has improved care for patients prescribed multiple medicines. The iSIMPATHY project, funded by the European Union's INTERREG VA Programme, worked with professionals in Scotland, the Republic of Ireland and Northern Ireland to comprehensively review patient medication. Taking multiple medicines can be problematic if the increased risk of harm from interactions between drugs, or between drugs and diseases, outweighs the intended benefits. Interim findings showed these interventions potentially prevented major organ failure, adverse drug reactions, avoided hospital admissions and saw patients moved to more appropriate medication. Scotland’s Public Health Minister Maree Todd said: “This project looked at some of our most vulnerable patients taking more than five medications. The reviews have avoided adverse combinations of drugs and hospitalisations while also reducing prescriptions and drugs costs. “We will know more when the full evaluation is published in June, we will work with partners to see how we can these improvements can be applied more widely, potentially saving lives and money.” Read full story Source: Scottish Government, 10 March 2023
  2. News Article
    The drug giant behind weight loss injections newly approved for NHS use spent millions in just three years on an “orchestrated PR campaign” to boost its UK influence. As part of its strategy, Novo Nordisk paid £21.7m to health organisations and professionals who in some cases went on to praise the treatment without always making clear their links to the firm, an Observer investigation has found. Among the vocal champions of the Wegovy jabs was a clinical expert who gave evidence to the National Institute for Health and Care Excellence (NICE) and others who publicly praised the so-called “skinny jabs” as a “gamechanger”. The revelations come as the Danish drug giant is investigated by the UK’s pharmaceutical watchdog after it was found to have breached the industry code seven times in relation to a “disguised promotional campaign” of another of its weight loss drugs via online webinars for healthcare professionals. Prof Allyson Pollock, professor of public health at Newcastle University, said Novo’s campaign was “not unusual” in the drugs industry and called for measures to improve trust. “The public really aren’t being made aware enough about the potential for bias and over-claiming,” she said. Read full story Source: The Guardian, 12 March 2023
  3. News Article
    A review into the culture at Birmingham's biggest hospitals trust amid allegations of bullying and undue pressure on staff has found 'substantial issues' of concern, a brief report has revealed. A short briefing for councillors by NHS Birmingham and Solihull chief executive David Melborne offers the first insight into the findings of Professor Mike Bewick and his review team who were tasked with investigating damning allegations made by current and former staff at University Hospitals Birmingham. More than 50 medics, including some with decades of experience, came forward to criticise a 'toxic' working culture at the trust, many sharing their experiences with MP Preet Kaur Gill (Birmingham Edgbaston). Among the most serious claims that emerged were that whistleblowers concerned about patient safety were silenced with threats of disciplinary action. In a written report to Birmingham and Solihull councils' joint health overview and scrutiny committee, meeting Monday, Mr Melborne says the rapid review into the Newsnight allegations and subsequent complaints has found 'no fundamental safety issues at the Trust'. However, he goes on: "That said, there are substantial issues around culture, behaviour, leadership and governance that will need to be addressed". Read full story Source: Birmingham Live, 10 March 2023
  4. News Article
    The U.S. Food and Drug Administration (FDA) is providing an update on reports of squamous cell carcinoma (SCC) in the scar tissue (capsule) that forms around breast implants. Previously, on 8 September 2022, the FDA released a safety communication informing the public of reports of cancers, including SCC and various lymphomas, in the capsule that forms around breast implants. The various lymphomas are not the same as the lymphomas described previously by the FDA as breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). This update includes information from the FDA’s review of literature and medical device reports (MDRs). The FDA is aware of 19 cases of SCC in the capsule around the breast implant from published literature. There have been reports in the literature of deaths from progression of the disease. While the FDA continues to believe that occurrences of SCC in the capsule around the breast implant may be rare, the cause, incidence and risk factors remain unknown. Read full story Source: US FDA, 8 March 2023
  5. News Article
    GPs are facing “insurmountable pressures”, experts have said as they warned that the NHS “will not survive” without general practice. A new report into GP pressures suggests one in four staff fear their practice is in danger of closing because of unmanageable workloads and rising demand. The document, from the Royal College of GPs (RCGP), says general practice is “in crisis”, and makes a series of calls to help ease pressures and stop the growing number of GPs from quitting. The report says GPs are bracing for “winter-style pressures” well into spring and summer. “The workload pressures in general practice over this winter have been immense, and high levels of patient demand are set to continue for some time,” the report authors wrote. “General practice is in crisis. We cannot rely on short-term emergency funding pots over winter to try and paper over the cracks." Read full story Source: The Independent, 10 March 2023
  6. News Article
    More than 500 seriously ill patients died last year before they could get treatment in hospital after the ambulance they called for took up to 15 hours to reach them, an investigation by the Guardian reveals. The fatalities included people who had had a stroke or heart attack or whose breathing had suddenly collapsed, or who had been involved in a road traffic collision. In every case, an ambulance crew took much longer to arrive than the NHS target times for responding to an emergency. Bereaved relatives have spoken of how the pain of losing a loved one has been compounded by the ambulance crew having taken so long to arrive and start treatment. Coroners, senior doctors and ambulance staff say the scale of the loss of life illustrates the growing dangers to patients from the implosion of NHS urgent and emergency care services. “These 500-plus deaths a year when an ambulance hasn’t got there in time are tragic and avoidable,” said Dr Adrian Boyle, the president of the Royal College of Emergency Medicine, which represents A&E doctors. “These numbers are deeply concerning. This is the equivalent of multiple airliners crashing.” Read full story Source: The Guardian, 9 March 2023
  7. Content Article
    Digital technologies can change how care is delivered, making health and care services more accessible, flexible, person centred, and a better experience for patients and staff while also improving efficiency. However, there is no guarantee of these positive effects until digitally enabled services are inclusive and meet the expectations of staff and the public. In this King's Fund long read, explore what digital exclusion is, who is commonly assumed to be excluded, and what can be done to mitigate digital exclusion.
  8. Content Article
    Appropriate capital funding is needed to bring long neglected parts of the NHS estate into the 21st century for staff and patients. From fixing leaking roofs and broken boilers, to transforming estates to make them fully digitised and sustainable, and enhancing diagnostic capacity, capital investment has the potential to transform the NHS – improving patients’ experience and making it more efficient and effective. This report from NHS Providers explores the state of capital funding and allocations across the NHS provider sector and how trusts can access capital. It highlights the extent of the dilapidated estate and make the case for strategic capital investment at both the system and national level to drive productivity, improve patient care, and enable much-needed transformation across the NHS.
  9. Event
    The pandemic struck just over a year after the Long Term plan was published, a year which was designed to lay the groundwork for many of the plan’s commitments. Some of this had progressed, for example new Primary Care Networks were created, but work on delivering many of the plan’s goals had only just begun when COVID-19 arrived. It’s clear that no part of the NHS Long Term Plan has been unaffected by the pandemic. The conference will build on collaboration during the pandemic across government departments, health and care organisations, local government, and voluntary, community and private sector organisations to prevent and mitigate some of the most pressing impacts of COVID-19 on the nation’s mental health and wellbeing and support people who are struggling. Register
  10. Content Article
    Last week, one of the country’s largest child and adolescent mental health services, Forward Thinking Birmingham, run by Birmingham Women’s and Children’s Foundation Trust, was rated “inadequate” by the Care Quality Commission. The inspection report makes for concerning reading — not least because it speaks to a range of issues being experienced by other providers of CAMHS services across the country. CQC inspectors warned there were not enough nursing and support staff to keep people using community services from avoidable harm. Nurses told the CQC that vacancies in the service impacted on people being allocated a care coordinator — and staff were leaving largely due to handling caseloads they felt were unsafe. Part of HSJ’s Mental Health Matters fortnightly briefing, covering safety, quality, performance and finances in the mental health sector.
  11. Content Article Comment
    Lots of discussions on Twitter on the guidelines. Don't forget consultation closes 13 March.
  12. Community Post
    I'm sorry to hear that @Blodwen There should be procedures in place at the private hospital to raise concerns directly with them as a complaint. However, if you have tried that and got nowhere, I would advise you to take a look at the AvMA website which provide clear and straightforward information on the steps you can take and guide you through making a complaint: AvMA - Complaints about NHS or private healthcare Also, PHIN has information on making a complaint as a private patient: PHIN - Making a complaint as a private patient I hope that helps.
  13. Content Article
    Green 4 Health is a new podcast series from Angela Hayes talking about the climate crisis and thinking green. It takes a light-hearted look at what’s going on in healthcare to make our planet greener and sustainable. Watch the latest podcast from the link below.
  14. Content Article
    In this Channel 4 Dispatches programme, secret footage filmed over the winter reveals ambulance workers battling the odds and A&E departments overwhelmed as patients suffer needless harm and death The footage comes from Daniel Waterhouse, an emergency medical technician who wore a body-mounted camera during his shifts in north-west London for three months this winter, filming every crumbling layer of a system that is close to total destruction.
  15. News Article
    The crisis in the NHS is leading to continued higher-than-usual death levels in England and Wales, experts have said. Figures from the Office for National Statistics reveal that almost 170,000 more people than normal died in England and Wales between March 2020, when coronavirus was declared a pandemic, and the end of 2022 – 11% higher than the five-year average. However, the new data also shows that the number of excess deaths has continued, even as the virus’s fatality rate has declined thanks to vaccinations and weaker strains, with 90% of the excess deaths in 2022 occurring in the second half of the year, coinciding with recent NHS pressures and the impact of a cold winter. Prof David Spiegelhalter of Cambridge University said that “analyses have suggested that delays in ambulance arrivals and in A&E will have had a substantial impact, as well as the cold weather and the early flu season”. Read full story Source: The Guardian, 9 March 2023
  16. News Article
    A trust has been issued with a warning notice after the Care Quality Commission (CQC) raised concerns about parts of its maternity services. Following a focused inspection at University Hospitals Dorset Foundation Trust in September and November last year, the CQC has rated maternity services at Poole Hospital “inadequate”, down from “good”. The service was also rated “inadequate” in the safety and well-led domains. The CQC report warned that Poole Hospital’s maternity unit did not always have enough midwifery or medical staff to keep mothers and babies safe. The inspectors noted this had led to delays to induction of labour and caesarian sections, including emergency sections. A warning notice was also issued over concerns about the unit’s emergency call bell system, which worked “intermittently” due to poor wireless signal, and processes used to summon help during an emergency. The trust said it had since “taken action to address this risk”. Read full story (paywalled) Source: HSJ, 10 March 2023
  17. News Article
    In posts on two Facebook forums, GP Survival and Resilient GP, family doctors write anonymously, revealing their concerns about how hard they sometimes find it to get an ambulance to attend to a sick patient – and the risks that can pose. “I ended up in the back of a police car with sirens going with a stranger who’d had a probable stroke on the street. Category 2 ambulance hadn’t come after 45 minutes so flagged down a cop car. They bundled us in. “Emergency department full of waiting ambulances unable to unload and I eventually left him in the very capable hands of the stroke team. Terrifying how broken our system is and how many people had likely just walked past him before I spotted him from my car." “Our emergency care practitioner called an ambulance at 6pm on Wednesday 6 July. Very elderly gentleman. Off legs, urinary symptoms, not eating/drinking. Guess when crew arrived? This morning, Friday 8 July, around 10am – 40 hours [later]. And the ECP had to wait 35 minutes just for 999 call to be answered!” “I recently complained [to the local ambulance service] for first time ever when ambulance refused to take a very sick patient of mine into hospital that I’d assessed over the phone because ‘her obs are normal’. They weren’t but even if they had been the reliance on these alone, ignoring the medical background, the family history and my history was just wrong. “I then had to go out and see her, re-call 999 (with many hours additional delay) and she died after a few days in hospital.” Read full story Source: The Guardian, 9 March 2023
  18. News Article
    A new scheme in Wales to help people who have suffered falls has prevented 50 ambulances being unnecessarily sent this year. St John Ambulance works with Hywel Dda health board in Pembrokeshire to send its people when someone calls 999. The pilot has been used 96 times since January but it needs more health board funding to continue after March. Ageing Well in Wales estimates that between 230,000 and 460,000 over 60s fall each year. When people dial 999, it can be directed to the St John Ambulance falls response team, who are sent to perform an assessment and identify whether the person can stay home or needs an ambulance to take them to hospital. St John Ambulance operational team leader Robert James said in 60% of cases, the person was well enough to stay at home. "You can imagine if you were sending an ambulance crew out and it has wasted 60% of the crew's time, well it's a big saving towards the NHS and the ambulance service in itself," he added. "Provided there are no injuries, or reason for them to go to hospital, they can be discharged on the scene." Read full story Source: BBC News, 10 March 2023
  19. Content Article
    The ‘improvement’ of healthcare is now established and growing as a field of research and practice. This article by Cribb et al., based on qualitative data from interviews with 21 senior leaders in this field, analyses the growth of improvement expertise as not simply an expansion but also a multiplication of ‘ways of knowing’. It illustrates how healthcare improvement is an area where contests about relevant kinds of knowledge, approaches and purposes proliferate and intersect. One dimension of this story relates to the increasing relevance of sociological expertise—both as a disciplinary contributor to this arena of research and practice and as a spur to reflexive critique. The analysis highlights the threat of persistent hierarchies within improvement expertise reproducing and amplifying restricted conceptions of both improvement and ‘better’ healthcare.
  20. News Article
    A surgeon who may have infected two new mothers with herpes has been granted anonymity during the inquests into their deaths in an "unprecedented" ruling. Coroner Catherine Wood said she made the decision because the surgeon's "apprehension" about being named when he stands as a witness would "likely impede his evidence in court" and affect his health. Mid Kent and Medway Coroners is investigating the cases of Kimberly Sampson, 29, and Samantha Mulcahy, 32, who both died in 2018 after the same obstetrician conducted their caesareans. They were treated 6 weeks apart in hospitals run by East Kent Hospitals University NHS Trust (EKHUT). On February 26 – the day before the inquest was due to begin and 16 months after it was first announced – EKHUT made a last-minute bid for anonymity covering the surgeon and a midwife also involved in both cases. The trust said they should not be named unless the inquest concluded they had passed on the infection, because of the "reputational damage" they would suffer, and because the surgeon's health was already being impacted by reports. Read full story Source: Medscape, 9 March 2023
  21. News Article
    A newly approved weight loss jab should be used with caution as it could be harmful to those vulnerable to eating disorders, doctors have warned. Thousands struggling with obesity could be prescribed Wegovy, or semaglutide, which scientists have described as a “game changer”, after the National Institute for Health and Care Excellence (NICE) approved its use. However, eating disorder experts have warned the NHS to proceed with caution in prescribing the drug, with one GP accusing NICE of being “absolutely reckless” in approving it. The drug was approved on Wednesday for use in adults who have at least one weight-related condition, such as type 2 diabetes, high blood pressure, high cholesterol sleep apnoea and heart disease, and a body mass index score of at least 35. It can only be prescribed to those undergoing weight management treatment. Read full story Source: The Independent, 8 March 2023
  22. Event
    until
    This Westminster conference will discuss next steps for improving health outcomes for children and young people in England. Delegates will assess the future of the new network of Family Hubs, with discussion on improving the coordination and accessibility of children’s care, as well as shifting focus towards early intervention and prevention, and improving the provision of support to families. It will be an opportunity to review progress on and next steps for The best start for life: a vision for the 1,001 critical days, which looks at providing support for local authorities in addressing the needs of children and their families, and consider the future of children’s health data. Further sessions will examine measures that were included in the Plan for Patients, which sets out to improve access to children’s mental health services, and enhance funding and regulation to reduce care backlogs. Overall, areas for discussion include: Family Hubs: progress made so far in implementation - addressing challenges in the transition to the family hub service model the role of community support - delivering long-term improvements to the lives of families - improving engagement and communication with families utilising the Family Hubs to improve coordination across support services - developing and sharing best practice across local authorities. Impact of poverty and cost of living pressures: latest thinking on approaches to mitigating the impact of poverty on child development understanding the economic pressures on families - addressing their impact children’s health implementing early intervention and prevention programmes - applying lessons learnt from the Surestart programme. Developing child health services: addressing waiting times and care backlogs - returning service provision to pre-pandemic levels. next steps for regulation and funding - the role of integrated care systems in supporting local needs. Mental health support: developing the community-based offer for mental health support - enabling service coordination meeting the increased demand for services - evaluating resource allocation early years development: progress made following publication of the final Leadsom Review - acting on the recommendations - the future for health visiting and child development checks. Digital health and data sharing: opportunities and issues arising from the use and sharing of child health data - increasing the quality of NHS records to improve outcomes - faster identification of health and social concerns latest thinking on data sharing practices - evaluating digital security provisions, Register
  23. Content Article
    The NHS Staff Survey is one of the largest workforce surveys in the world and is carried out every year to improve staff experiences across the NHS. It asks staff in England about their experiences of working for their respective NHS organisations. 636,384 staff responded to the survey in 2022. The full results of the 2022 NHS Staff Survey are published on the NHS Staff Survey website.
  24. News Article
    Progress being made on tackling the hospital waiting backlog will be put at risk by next week's junior doctors' strike, NHS bosses are warning. NHS England medical director Prof Sir Stephen Powis said there had been huge achievements over the winter. But he said it was inevitable the 72-hour walkout in England, which starts on Monday, would have an impact. It comes as the annual NHS staff survey shows a falling number happy to recommend the care at their service. The poll found 63% would be happy to see a friend or relative treated - down by five percentage points in the past year and 11 over two years. Meanwhile, latest performance data shows NHS emergency services are continuing to miss their targets, although the situation is not getting worse. Dr Tim Cooksley, president of the Society for Acute Medicine, said despite the situation not getting worse it still presented a "damning" picture, and warned it was "increasingly causing harm to patients". Read full story Source: BBC News, 9 March 2023
  25. News Article
    Nine care home workers are facing trial for neglecting, verbally abusing and deliberately antagonising extremely vulnerable patients in care described as “devoid of kindness and respect” but also criminal. The six men and three women, aged 25-54, are being prosecuted after a reporter went undercover and filmed the behaviour for a BBC Panorama documentary. Opening the case at Teesside crown court in Middlesbrough, the prosecuting barrister, Anne Richardson, said the patients all resided at Whorlton Hall, a 17-bed independent specialist hospital unit near Barnard Castle, County Durham, operated by Cygnet Health Care. Richardson said caring for such residents was a “hard, demanding job, and that carers can face complex, difficult, obstreperous, and sometimes violent people who sadly do not realise what they are doing and cannot help their actions.” But they deserved to be treated with “kindness, respect and patience.” Richardson said the jury would hear evidence of ill-treatment which was “cruel and abusive”. It was “not only devoid of the respect and kindness that those residents deserved but was also a criminal offence”. It included care workers repeatedly saying words they knew to be triggers to patients, belittling those in their care and deliberately antagonising them. Read full story Source: The Independent, 8 March 2023
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