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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    NHS Ambulance service have a “fear of speaking up” amid pervasive “cliquey”, sexist, racist and homophobic cultures, a watchdog has warned. A national guardian has warned of negative cultures in trusts preventing workers from raising concerns as she called for a “cultural review” of ambulance organisations. The review into whistleblower concerns, by the Freedom to Speak Up Guardian’s office, has found widespread cultural issues including clique-like behaviour and bullying and harassment. Dr Jayne Chidgey-Clark, the NHS National Freedom to Speak Up Guardian, has now called on ministers and the NHS to independently review ambulance services, after speaking with ambulance staff across five NHS trusts. The report has called for a cultural review of the ambulance service by NHS England, the Care Quality Commission, the Association of Ambulance Chief Executives and ministers. Read full story Source: The Independent, 24 February 2023
  2. Content Article
    The National Guardian’s Office has published Listening to Workers – the report following its Speak Up review of NHS ambulance trusts in England. The review found the culture in ambulance trusts did not support workers to speak up and that this was having an impact on worker wellbeing and ultimately patient safety.
  3. News Article
    Progress to cut the number of women dying in pregnancy or childbirth has stalled or even reversed in recent years, with a death recorded every two minutes, the United Nations has said. Years of gains had begun to plateau even before the pandemic and there had been “alarming setbacks for women’s health,” according to a new report from several UN agencies, including the World Health Organization (WHO). Maternal mortality rates had fallen widely in the first 15 years of the century, but since 2016, they had only dropped in two UN regions: Australia and New Zealand, and in Central and Southern Asia. The rate went up in Europe and North America by 17% and in Latin America and the Caribbean by 15%. Elsewhere it stagnated. Read full story (paywalled) Source: The Telegraph, 23 February 2023
  4. Content Article
    Every day in 2020, approximately 800 women died from preventable causes related to pregnancy and childbirth - meaning that a woman dies around every two minutes. Sustainable Development Goal (SDG) target 3.1 is to reduce maternal mortality to less than 70 maternal deaths per 100 000 live births by 2030. This report presents internationally comparable global, regional and country-level estimates and trends for maternal mortality between 2000 and 2020.
  5. News Article
    An ‘outstanding’ rated acute trust has been served with a warning notice by the Care Quality Commission (CQC) and told to make ‘significant and immediate improvements’ to its mental health and learning disabilities services. The CQC said staff at Newcastle upon Tyne Hospitals Foundation Trust had not always carried out mental capacity assessments when people presented with mental health needs. And this included when decisions were made to restrain patients in the emergency department. A CQC warning notice, published alongside a report of an inspection between 30 November and 1 December last year, says the trust must make “significant and immediate improvements in the quality of care being provided” to people with mental health issues, learning disabilities or autism. The warning notice also says the trust must ensure people with a learning disability and autistic people “receive care which meets the full range of their needs”. The trust’s records “did not show evidence that staff had considered patients’ additional needs,” the regulator said. Read full story (paywalled) Source: HSJ, 24 February 2023
  6. News Article
    Britain could double the number of doctors and nurses it trains under NHS plans to tackle a deepening staffing crisis, according to reports. The proposal to increase the number of places in UK medical schools from 7,500 to 15,000 is contained in a draft of NHS England’s long-awaited workforce plan, which is expected to be published next month. Labour has already announced this policy as a key element of its plans to revive the NHS. However, it could face opposition from the Treasury because of how much it would cost, according to the Times, which reported on the plan. The NHS in England alone is short of 133,000 staff – equating to about a tenth of its workforce – including 47,000 nurses and 9,000 doctors, according to the most recent official figures. There are also shortages of midwives, paramedics and operating theatre staff. Staff groups say routine gaps in NHS care providers’ rotas are endangering patients’ safety, increasing workload and costing the service money. Read full story Source: The Guardian, 22 February 2023
  7. News Article
    Nearly half of NHS patients with a learning disability or autism are still being kept inappropriately in hospitals, several years into a key programme to reduce inpatient care, a national review reveals. The newly published review by NHS England suggests 41% of inpatients, assessed over an eight-month period to May 2022, should be receiving care in the community. Reasons given for continued hospital care in the NHSE review included lack of suitable accommodation, with 19% having needs which could be delivered by community services; delays in moving individuals into the community with appropriate aftercare; legal barriers, with one region citing “ongoing concerns for public safety” as a barrier for discharge; and no clear care plans. In some cases, individuals were placed in psychiatric intensive care units on a long-term basis, because “there was nowhere else to go”, while another instance cited a 20-year stay in hospital. Other key themes included concerns about staff culture, particularly “institutionalisation” and suggestions that discharge delays were not being sufficiently addressed. The report adds: “While the process around discharge can be time consuming, staff may perpetuate this by accepting such delays as necessary or inevitable.” Read full story (paywalled) Source: HSJ, 22 February 2023
  8. Content Article
    This report details the findings of a thematic review of Safe and wellbeing reviews (SWRs) between October 2021 and May 2022. SWRs are undertaken for children, young people and adults that are autistic and/or have a learning disability who are being cared for in a mental health inpatient setting.  SWRs are part of the NHS response to the safeguarding adults review concerning the tragic deaths of Joanna, Jon, and Ben at Cawston Park Hospital, who were each detained for a long period of time and did not receive appropriate care.
  9. Content Article
    More and more people are dying at home, rather than in a hospital or hospice. With this trend set to continue, how can commissioners ensure that end-of-life care reflects this and meets the needs of people approaching the end of their lives and their loved ones?   This new report from the King's Fund explores what we know about commissioning end-of-life care, the inequalities experienced by particular groups, and how NHS and social care commissioners in England are measuring and assuring the quality of care people receive.   Drawing on interviews with commissioners, stakeholders and experts in end-of-life care, as well as recently bereaved carers and family members, this report offers reflections and recommendations for those wanting to improve end-of-life care for those dying at home.
  10. Content Article
    The Patient Safety Friendly Hospital Initiative (PSFHI) aims to address the burden of unsafe care in the Eastern Mediterranean Region. It helps institutions in countries of the Region to launch comprehensive patient safety programmes, with assistance from the World Health Organization (WHO).
  11. Event
    Implemented as part of two projects, "Improving health literacy for better public and patient involvement in mitigating COVID-19 pandemic using interactive and intuitive educational tools" & "Protecting the value of access to care during - and after - the COVID-19 pandemic across Europe: focus on antivirals", the training sessions will be addressed to representatives of Civic and Patients' Associations from across Europe. The events, which will be held in English, will provide a common set of up-to-date information, share experiences, identify lessons learned, and also obtain feedback from the associations. There will be two separate sessions: 1) "Knowing and Mitigating the Impact of COVID-19" with these main topics: Essential language and dangerous beliefs Virus mutations, how they happen and what to expect What should we expect (and not expect) from the anti-COVID-19 vaccine? Antibiotic use in COVID-19, when is it appropriate? 2) "The value of access to care: focus on antivirals" on: Treatments and approved drugs: to whom and how? The role of antivirals Complications of the disease, not only lungs. Symptoms of "Long Covid," how to identify it and what to do; Do vaccines have a role? Cancer prevention and screening: the great absentees in the pandemic. Register
  12. News Article
    Wearable fitness and wellness trackers could interfere with some implanted cardiac devices such as pacemakers, according to a study. Devices such as smartwatches, smart rings and smart scales used to monitor fitness-related activities could interfere with the functioning of cardiac implantable electronic devices (CIEDs) such as pacemakers, implantable cardioverter defibrillators (ICDs), and cardiac resynchronisation therapy (CRT) devices, the study published in the Heart Rhythm journal found. Researchers found that the electrical current used in wearable smart gadgets during “bioimpedance sensing” interfered with proper functioning of some implanted cardiac devices from three leading manufacturers. Lead researcher, Dr Benjamin Sanchez Terrones, of the University of Utah. said the results did not convey any immediate or clear risks to patients who wear the trackers. However, the different levels of electrical current emitted by the wearable devices could result in pacing interruptions or unnecessary shocks to the heart. Further research was needed to determine the actual level of risk". “Our research is the first to study devices that employ bioimpedance-sensing technology as well as discover potential interference problems with CIEDs such as CRT devices. We need to test across a broader cohort of devices and in patients with these devices. Collaborative investigation between researchers and industry would be helpful for keeping patients safe,” Sanchez said. Read full story Source: The Guardian, 22 February 2023
  13. News Article
    Prostate cancer screening may be a step closer after a study suggested that harms linked to testing have reduced thanks to advances in medical technology. Screening for prostate cancer has been heavily debated in medical circles due to potential harms including side effects from biopsies and unnecessary testing for those with no clinically significant cancer. A new study set out to examine whether the “seesaw has been tipped” in favour of screening. Researchers from Prostate Cancer UK combined the results of the latest clinical trials and real-world data on the “prostate cancer screening pathway” to examine the risk-to-harm benefit. Prostate Cancer UK said that on average 67%t fewer men experienced harm during the diagnostic process with the newer techniques compared with older methods. Prostate Cancer UK said the UK National Screening Committee, which makes recommendations to the Government, is to re-examine prostate cancer screening. Dr Matthew Hobbs, lead researcher on the analysis and director of research at Prostate Cancer UK, said: “We’ve known for some time now that testing more men reduces prostate cancer deaths, but there have always been concerns about how many men would be harmed to achieve this. “However, our evidence shows that screening may now be a lot safer than previously thought. That’s why we are so pleased that the committee is going to review the evidence once more. Read full story Source: The Independent, 23 February 2023
  14. Content Article
    The e-learning module, Human Factors in health care includes seven videos and is available free to all health care professionals  via the LearnOnline platform. The module has been produced by the New Zealand Health Quality & Safety Commission, funded by the Accident Compensation Corporation (ACC) and supported by WorkSafe.
  15. News Article
    An acute trust and its integrated care system have said they risk missing the imminent waiting list target, after struggling to get as many patients treated in the independent sector as they hoped. University Hospitals of North Midlands Trust and Staffordshire and Stoke-on-Trent ICS have found that some patients who had earlier been referred to independent providers, had then, while waiting for IS treatment, got sicker or became high risk to such an extent that they needed to be referred back to UHNM. Other patients have declined being transferred to the independent sector, board meetings heard. Phil Smith, chief delivery officer at Staffordshire and Stoke-On-Trent Integrated Care Board, told its meeting last week he needed to “flag an escalated risk” to meeting the target, after deterioration in activity “linked to industrial action, linked to the willingness of patients to be treated in the independent sector and the independent sector’s ability to treat patients”. Read full story (paywalled) Source: HSJ, 22 March 2023
  16. News Article
    Record levels of NHS staff are seeking mental health help as clinicians warn the “crisis” facing workers is “worse than the pandemic”. Hundreds of staff are being referred to the specialist mental health service, NHS Practitioner Health, with 842 workers referred in October 2022 – up from 534 in the same month the year before and 371 in 2020. Around 40% of the staff seeking the service are GPs and 50% are hospital doctors. The news comes as The Independent reported that the NHS and government are set to axe funding for 40 mental health hubs set up for health and social care workers following the pandemic. Amandip Sidhu, of Doctors in Distress, which offers workers mental health support, said: “Health workers believe that the crisis they are currently dealing with is worse than during the pandemic and exacerbated by the fact there is no end in sight, with little evidence that decision-makers are taking steps to improve the situation. “The fact that the public, their patients, lack sympathy or understanding is making many medics feel isolated and completely unappreciated.” Read full story Source: The Independent, 23 February 2023
  17. News Article
    White applicants remain 54% more likely to be appointed from NHS job shortlistings compared to ethnic minority candidates, a metric that has hardly budged since 2016, a NHS England report has revealed. The 2022 NHS workforce race equality standard report, revealed a significant rise in the proportion of staff from ethnic minority backgrounds. And while there had been progress on some key targets since last year, others have stagnated. NHSE’s report showed ethnic minority staff comprise 24.2% of the workforce in 2022, up from 22.4% last year and from 17.7% six years ago. However, it also revealed the likelihood of white applicants being appointed from shortlists was 1.54 in 2022 than minority ethnic applicants – only a very small improvement on 1.57 in 2016, when WRES began Read full story (paywalled) Source: HSJ, 22 February 2023
  18. Content Article
    The 2022 Workforce Race Equality Standard (WRES) report enables organisations to compare their performance with others in their region and those providing similar services, with the aim of encouraging improvement by learning and sharing good practice. It provides a national picture of WRES in practice, to colleagues, organisations and the public on the developments in the workforce race equality agenda The WRES provide detailed analysis to enable employers to understand how their staff experience compares with others in their region and with similar specialism.
  19. News Article
    A trust has admitted it ‘missed opportunities’ to identify that a locum doctor – who was arrested on hospital premises for two sexual offences — had already been cautioned for indecent exposure. Salman Siddiqi admitted two offences – attempting to engage in sexual communication with a child and attempting to arrange or facilitate a meeting with a child for sexual offences – last month. East Kent Hospitals University Foundation Trust, where he was working as a locum paediatric registrar at the time of the January offences, has now said there had been “missed opportunities” to identify his previous caution. Chief medical officer Rebecca Martin told HSJ the trust had taken steps to ensure that these missed opportunities could not happen again. She said in a statement: “This includes standardising DBS checks for temporary workers booked through an agency and escalating all DBS and General Medical Council checks that feature conditions, cautions or warnings.” Read full story (paywalled) Source: HSJ, 23 February 2023
  20. News Article
    People from ethnic minority backgrounds are no longer significantly more likely to die of Covid-19, new Office for National Statistics (ONS) data shows. Early in the pandemic, deaths involving coronavirus were higher among black and Asian people than white people, with the highest risk among Bangladeshi, Black Caribbean and Pakistani groups. Covid mortality rates for all ethnic minorities decreased last year. The latest data shows there is no significant statistical difference between the number of Covid deaths among ethnic minorities and the white population. The ONS also said that "all cause" mortality rates - measuring how likely people are to die of any cause, including Covid-19 - have returned to pre-pandemic patterns. The reasons for this change are complex, and experts say there are "various factors" to consider. Read full story Source: BBC News, 22 February 2023
  21. News Article
    Doctors at an east London hospital say they are seeing so many risky cases of laughing gas misuse that they have drawn up treatment guidelines for colleagues in the UK. Nitrous oxide, sold in metal canisters, is one of the most commonly used drugs by 16 to 24-year-olds. Heavy use can lead to a vitamin deficiency that damages nerves in the spinal cord. The Royal London Hospital team say medics need to be on alert. They have been seeing a new case almost every week. The guidelines, endorsed by the Association of British Neurologists and written with experts from Manchester, Birmingham, Nottingham and the Queen Mary University of London, warn doctors what to look for and how to treat. Read full story Source: BBC News, 23 February 2023
  22. Content Article
    Surprises in healthcare are common and can have lasting effects on clinicians. Steven Shorrock asked clinicians to reveal aspects of their experience with implications for learning.
  23. Content Article
    Electronic prescribing (ePrescribing) systems allow healthcare professionals to enter prescriptions and manage medicines using a computer. Sheikh and colleagues set out to find out how these ePrescribing systems are chosen, set up and used in English hospitals. Given that these systems are designed to improve medication safety, we looked at whether or not these systems affected the number of prescribing errors made (mistakes such as ordering the wrong dose of medication). They also tried to see whether or not the systems were good value for money (or more cost-effective). Finally, they made recommendations to help hospitals choose, set up and use ePrescribing systems.
  24. News Article
    A US government watchdog called for greater federal oversight of ethics boards that sign off on scientific studies, finding that for-profit companies have taken an outsize role in approving certain research and questioning whether financial motivations could put human subjects at risk. Federal regulations require that certain research on human subjects — including those testing the safety of new drugs — first get approval from a registered institutional research board. These boards, which are made up of at least five members and can include researchers and academics, are designed to make sure that a study poses as little risk as possible and that participants have enough information to give consent. While the majority of these boards are affiliated with universities, a small number have no affiliation with institutions conducting research. But according to a new report from the U.S. Government Accountability Office (GAO), these independent boards now account for the largest share of reviews of studies involving new drugs and biologics. The GAO found that federal agencies overseeing the ethics panels inspect relatively few of them and lack ways to evaluate how well they protect people participating in research. Read full story (paywalled) Source: The Washington Post, 16 February 2023
  25. News Article
    NHS England has lost an employment tribunal case against a senior black nurse on grounds of race discrimination and whistleblowing, and has been criticised for serious flaws in its own investigations. A judgement published today found Michelle Cox, a black woman who was an NHS continuing healthcare manager based in NHSE’s North West regional team, was excluded by her manager “at every opportunity”. The case centres on problems between Ms Cox and her line manager, then regional head of continuing healthcare, which took place from around April 2019 to November 2020. The tribunal ruled Ms Cox's line manager– who is now an associate director of nursing in the West Yorkshire integrated care system – had created an “intimidating and hostile and humiliating environment” for Ms Cox, which had the purpose and effect of unlawful harassment. The tribunal also upheld Ms Cox’s complaint of detriment for whistleblowing, including for raising concerns that members of her team were sitting on continuing healthcare “independent review panels”, which she pointed out was a breach of independence and legal obligations. Read full story Source: HSJ, 22 February 2023
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