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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    A high-profile £250m government intervention to free up hospital beds has so far failed to deliver any significant reduction in delayed discharges – with multiple systems instead reporting large increases. Steve Barclay announced the fund, including £200m to buy step-down residential care beds to speed up discharges, on 9 January, following a “recovery forum” crisis summit at 10 Downing Street. NHS England said in guidance on 13 January the funding must bring “immediate improvements”, and local leaders were again told to “maximise the impact of their areas’ allocation of the money in the run up to strikes on 6 February”. But according to official data, in the week the new money was announced, there was an average of 14,035 patients who did not meet the clinical “criteria to reside”, but were still waiting to leave hospital, equating to around one in seven occupied beds. The total numbers have barely changed since then, with an average of 13,975 cases reported in the week to 5 February, also representing one in seven occupied beds. Read full story (paywalled) Source: HSJ, 13 February 2023
  2. News Article
    A damning report last year from Dr Hilary Cass into the Tavistock Gender Identity Development Service (GIDS) found that it was putting children at “considerable risk”. Her full report is due to be published later this year. Whistleblower Dr Anna Hutchinson, a senior clinical psychologist at GIDS, describes when she realised something was very wrong. “I just couldn’t comfortably keep being part of a process that was, I felt, putting children — but also my colleagues — at risk,” Hutchinson explains. Faced with no discernible action from the executive, staff began to look for other ways to raise their concerns, to other people who might listen — and act. Hutchinson approached the Tavistock’s Freedom to Speak Up guardian. At least four other colleagues did the same in 2017. That same year, another four clinicians took their concerns outside GIDS to the children’s safeguarding lead for the Tavistock trust." Read full story (paywalled) Source: The Times, 13 February 2023
  3. News Article
    Emergency patients are being left open to abuse when they are at their most vulnerable because of a lack of vetting of ambulance workers, watchdog officials have warned. One watchdog official warned that abusers would even seek out work as a paramedic because it provided an “attractive environment” for exploitation. Figures show that dozens of ambulance workers have faced action over sexual assault in the past two years, while paramedics account for one in three cases of tribunal action against care professionals. But one survivors’ group warned the figures were just the “tip of the iceberg”. Paramedics who have been struck off in the past two years include one who performed a sex act in front of a patient, while another was handed a suspended prison sentence for possessing thousands of images of child pornography. Helen Vine, special adviser to the Care Quality Commission, told a recent webinar: “There is a small proportion of the population who are seeking to abuse our patients and the ambulance can be an attractive environment for that type of individual. One of the reasons for this is the ambulance sector is predominantly lone working … and ambulance services offer privileged often unsupervised access to patients who can be very vulnerable". She said the lack of checks meant offenders were able to move between providers, adding: “They test the waters and their behaviours ... if they are challenged, they will move on, however, if they are not challenged then they can hide in plain sight, and they are wearing a trusted uniform and given responsible access to that patient group. Read full story Source: The Independent, 12 February 2023
  4. News Article
    Ambulance staff will need to respond to category 2 calls during strike action under new government proposals. The Department of Health and Social Care has launched a consultation on minimum service levels in ambulance services. It comes as industrial action continues across the NHS and as legislation to ensure minimum services levels in key industries during strikes is making its way through Parliament. The consultation document read: “Our proposal is that calls classed as life-threatening and emergency incidents would always receive an appropriate clinical response when there is strike action. “In England, currently, these calls are classified as category 1 (immediately life-threatening) and category 2 (emergency) calls… “On strike action days, some workers would continue their work to ensure that these calls can be answered and responded to appropriately to protect the life and health of patients.” The proposals added services must also have “adequate capacity and resourcing” in call control rooms, to ensure all emergency 999 calls to ambulance services were answered. Read full story (paywalled) Source: HSJ, 13 February 2023
  5. News Article
    Some of the country’s most senior NHS clinicians are earning a lucrative sideline running private firms that offer to cut waiting lists at their own hospitals, the Observer can reveal. Top consultants in Manchester, Sheffield and London are among directors of “insourcing” agencies that charge the health service to treat patients at weekends and evenings and have won millions of pounds of work. Some hold leadership roles at NHS trusts that have awarded contracts to their own companies, raising concerns about potential conflicts of interest. One deputy medical director jointly ran a firm that provided “insourcing” solutions to his own NHS trust before it was sold in a £13m deal last year. Other consultants have set up firms that they and their colleagues work shifts through themselves, often at rates above NHS price caps. The Centre for Health and the Public Interest, an independent thinktank, called for a ban on such arrangements. The General Medical Council said current conflict of interest policies did not always deliver “the transparency and assurance that patients rightly expect”. Read full story Source: The Guardian, 12 February 2023
  6. News Article
    Nitrous oxide levels on Watford General Hospital's maternity suite far exceeded legal limits during peak periods, a BBC investigation has found. In February 2022, air monitoring showed levels of almost 5,000 parts per million (ppm) - 50 times what is safe. The hospital's trust said it had since installed machines to remove the gas. It was one of a number of nitrous oxide incidents reported by NHS trusts to the Health and Safety Executive (HSE), Freedom of Information data has shown. The HSE disclosed the details following a request for its notifications under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR). There were 11 notifications to the HSE between August 2018 and December 2022 from seven NHS trusts and one private hospital in relation to nitrous oxide - almost all relating to maternity units. Monitoring has led to a string of NHS trusts suspending the use of Entonox - a mixture of nitrous oxide and air used to assist women in labour with pain relief. NHS bosses acknowledge there is "limited research on the occupational exposure to Entonox, and the long-term health risks this may pose", though at least one expert has played down the risk. But staff working in maternity units face uncertainty due to prolonged periods of time spent in affected areas, with particular concerns over Vitamin B deficiency due to exposure. Read full story Source: BBC News, 13 February 2023
  7. News Article
    Nurses in England are preparing to escalate their dispute with the government by involving staff from NHS A&E departments, intensive care and cancer wards in a series of 48-hour strikes. The Royal College of Nursing (RCN) is understood to be planning to announce walk outs for two consecutive days and nights, rather than limiting action from 8am to 8pm as they have done so far. NHS leaders warned the looming strike could be the “biggest impact” on patients yet seen, with the union preparing to end a process where the RCN had agreed to exemptions with hospitals. The RCN told NHS leaders on Friday it is preparing to step up its dispute by asking its members working in emergency departments, intensive care units and oncology to join the strike. But the union, expected to announce the strike this week, will make a very limited set of provisions for the most urgent clinical situations as part of a legal obligation not to endanger life. Saffron Cordery, deputy chief executive at NHS Providers said: “A continuous 48-hour strike that includes staff from emergency departments, intensive care units and cancer care services would likely have the biggest impact on patients we’ve seen.” Read full story Source: The Independent, 12 February 2023
  8. News Article
    A health watchdog has issued an unprecedented warning over patient safety, culture and leadership at a scandal-hit NHS trust,The Independent has learned. The Parliamentary Health Service Ombudsman, the government body that investigates patients’ complaints, has used powers for the very first time to raise “serious concerns” about University Hospitals Birmingham Foundation Trust. The body does not have its own powers to intervene but the warning has triggered an investigation by NHS England. Ombudsman Rob Behrens said there needed to be “significant improvements” in culture and leadership at the trust. He also raised concerns that the trust had failed to “fully accept or acknowledge” the impact of findings from investigations on patient safety. The decision to trigger the alert, known as the emerging concerns protocol, was “not taken lightly”, Mr Behrens said. Read full story Source: The Independent, 12 February 2023
  9. Content Article
    Tayo Oke talks to Kathy Oxtoby about why her chosen specialty of colorectal surgery is her “natural home” and the rewards of developing strong bonds with patients.
  10. News Article
    President Biden has endorsed “harm reduction,” which aims to cut down on overdoses by encouraging safer drug use. But the organizations carrying out that strategy are severely underfunded. In his State of the Union address on Tuesday, Mr Biden, the first president to endorse the strategy, highlighted the federal government’s attention to some of the core features of harm reduction work, including a provision in a recently enacted spending package that makes it easier for doctors to prescribe buprenorphine, an effective addiction medication that Ms Krauss works to get to drug users. During his speech, Mr Biden recognised the father of a 20-year-old from New Hampshire who died from a fentanyl overdose, citing the more than 70,000 Americans dying each year from the potent synthetic opioid. But two years after Mr Biden took office, with the nation’s drug supply increasingly complex and deadly, the practice of harm reduction remains underfunded and partially outlawed in many states. Read full story (paywalled) Source: New York Times, 10 February 2023
  11. News Article
    CVS Health confirmed last year it was closing half its Coram home infusion branches and firing about 2,000 nurses, dietitians and pharmacists. Their patients with life-threatening digestive disorders depend on parenteral nutrition, or PN — in which amino acids, sugars, fats, vitamins and electrolytes typically are pumped through a catheter into a large vein near the heart. A day later Optum Rx, another big supplier, announced its own consolidation. Suddenly, thousands were scrambling for their complex essential drugs and nutrients. “With this kind of disruption, patients can’t get through on the phones. They panic,” said Cynthia Reddick, a senior nutritionist laid off last summer in the CVS restructuring. “It was very difficult. Many emails, many phone calls, acting as a liaison between my doctor and the company,” said Elizabeth Fisher Smith, a 32-year-old public health instructor in New York, whose Coram branch closed. A rare medical disorder has forced her to rely on PN for survival since 2017. “It added to my mental burden,” she said Home and outpatient infusions in the USA are a growing business, as new drugs for chronic illness expand treatment options and enable patients, providers and insurers to avoid hospitalisation. But while reimbursement for expensive new drugs has attracted corporations and private equity, the industry is constrained by a lack of nurses and pharmacists. The less profitable parts of the business — and the vulnerable patients they serve — are at risk. This includes the 30,000-plus Americans who rely on parenteral nutrition — including premature infants, post-surgery patients and those with damaged bowels because of genetic defects. Read full story (paywalled) Source: The Washington Post, 6 February 2023
  12. Content Article
    Last year we published a blog from Dr Chelcie Jewitt on the Surviving in Scrubs campaign. The campaign was created by Dr Becky Cox and Dr Chelcie Jewitt to give a voice to women in healthcare to raise awareness and end sexism, sexual harassment and sexual assault in healthcare. On their Surviving in Scrubs website they share the awful stories from women working in healthcare of sexism, sexual harassment and sexual assault.
  13. Content Article
    In this BMJ opinion piece, Scarlett McNally discusses the revised National Safety Standards for Invasive Procedures (NatSSIP2). The original NatSSIPs were designed to prevent “never events”—yet more than 300 occurrences of wrong site surgery, retained objects after procedure, or wrong implant insertion still occur yearly in the UK.  NatSSIP2 brings in safety science and human factors, with expectations for organisations including standardisation, harmonisation, training, and audit. "The biggest danger is if the new standards sit on the shelf. With their benefits for patient safety and teamworking, we must accept the repetitive elements and consistently apply these new standards, every time, in every department", writes Scarlett.
  14. News Article
    Children suffering mental health crises spent more than 900,000 hours in A&E in England last year seeking urgent and potentially life-saving help, NHS figures reveal. Experts said the huge amount of time under-18s with mental health issues were spending in A&E was “simply astounding” and showed that NHS services for that vulnerable age group were inadequate. Children as young as three and four years old are among those ending up in emergency departments because of mental health problems, according to data obtained by Labour. Dr Rosena Allin-Khan, the shadow mental health minister, who is also an A&E doctor, said: “With nowhere to turn, children with a mental illness are left to deteriorate and reach crisis point – at which time A&E is the only place left for them to go. Emergency departments are incredibly unsuitable settings for children in crisis, yet we’re witnessing increasingly younger children having to present to A&E in desperation.” Young people who endured long A&E waits included those with depression, psychosis and eating disorders as well as some who had self-harmed or tried to kill themselves, doctors said. Read full story Source: The Guardian, 9 February 2023
  15. News Article
    A woman who underwent needless surgery at the hands of convicted surgeon Ian Paterson said patient safety was still not being prioritised. Paterson was convicted of 17 counts of wounding with intent in 2017 and was jailed for 20 years. Debbie Douglas, who now campaigns for his victims, said more still needed to be done following a damning report. In December, the Department for Health said it was making "good progress" on changes. The inquiry, published in 2020, made 15 recommendations and Ms Douglas called on health chiefs to "get on" with the improvements. "It's three years and technically none of the recommendations are closed," she said. "It's all around patient safety and it's not being given the priority it deserves." Read full story Source: BBC News, 9 February 2023
  16. News Article
    Changes to hip and knee surgery could halve waiting lists at one hospital within a year, say doctors. Tweaks to surgeries at the Princess of Wales hospital in Bridgend have allowed more patients to be sent home on the same day. Therefore, a shortage of hospital beds is not a barrier for them. It comes as over 37,000 orthopaedic patients are waiting over one year for surgery in Wales. Consultant orthopaedic surgeon Keshav Singhal said a number of "minor tweaks" were made to the procedure "but all of them add up to a huge effect". He said the anaesthetic and pain medication given to patients is "fine-tuned" to reduce pain and nausea after the operation and extra time is spent pinpointing any potential area of bleeding and cauterising it to "prevent wound leakage". "In day surgery we are not constrained by beds - there are no beds here," said Mr Singhal. "Patients can come in, be very well cared for in a state of the art day-surgery unit, and go home in the evening, and that totally cuts down on the inpatient beds." Read full story Source: BBC News, 10 February 2023
  17. News Article
    Ambulance crews reached emergencies such as heart attacks and strokes one hour quicker in January than December in England, figures show. They took 32 minutes on average, compared with more than 90 the month before. The target is 18 minutes but January's average was the quickest for 19 months. A&E waiting times also improved, with just over a quarter of patients waiting longer than four hours - down from more than a third in December. But Society for Acute Medicine president Dr Tim Cooksley said wait times remained "intolerable". And he highlighted the waits the sickest and most frail were facing for a bed on a ward. Nearly four out of every 10 patients waited over four hours on trolleys and in corridors. "The fundamental problem remains a significant shortage of workforce, leading to woefully inadequate inpatient bed and social-care capacity," Dr Cooksley added. Read full story Source: BBC News, 9 February 2023
  18. News Article
    More than a third of delayed discharges for long-stay patients are being caused by factors generally associated with the NHS, according to new data obtained by HSJ. Delayed discharges from hospital are often blamed on issues around social care, but figures for the nine months to January, for patients who have been in hospital for at least 21 days, suggest a significant proportion are due to NHS-related delays. The most common reason is waiting for rehabilitation beds in a community hospital or similar facility, which accounts for 23% of total delayed discharges, based on daily averages. Other reasons generally associated with NHS-related issues included delays around medical decisions (4%), therapist decisions (4 per cent), transfers to another acute site (2%), and diagnostic tests (1%). On top of this, a further 12% of the causes were at least partly associated with the NHS, such as delays relating to transfer of care hubs, which are generally jointly run with councils. Read full story (paywalled) Source: HSJ, 9 February 2023
  19. Content Article
    Dr Gordon Caldwell shares how he changed his whole approach to ward rounds after seeing spaghetti maps of where a nurse walked during a shift. He cut down walking distance on rounds by creating a mobile office on wheels out of an old electricians trolley. See also: Making the ward a more efficient place: a qualitative evaluation of the impact of the Vista 90 trolley  
  20. News Article
    A law firm that routinely advises health service bosses faces claims it withheld evidence in a landmark NHS whistleblowing case. A judge has called for full evidence disclosure to assess claims that healthcare specialist firm Hill Dickinson acted fraudulently in a dispute over a lack of legal protection for NHS doctors in whistleblowing claims. The firm will now have to account for its actions in litigation that saw more than 50,000 doctors below consultant level in England deprived of legal whistleblowing protections, according to the junior medic at the centre of it, Chris Day. The case also had implications for 865,000 agency workers across other sectors – including construction. Read full story Source: ByLine Times, 9 February 2023
  21. Content Article
    After Steve Burrow’s mother was harmed by medical care in Wisconsin, he took time out from his successful film career to advocate for her. In this episode of Lit Health, he touches upon his fascinating career, why stories matter, and delves deeply into his experience with the medical system, its need for policy reform and the role he has taken on as an advocate in this space with host, Tracy Granzyk. Lit Health podcasts interview authors, healthcare leaders, and policymakers working to create a healthcare environment that is equitable, transparent, and that welcomes the needs of every patient – especially our vulnerable populations including the mentally ill, people of colour and women who feel they are at risk in our current system, the elderly, and anyone who feels bias or the isms affect their health and quality of life. You can also watch Steve Burrow's documentary: Bleed Out,
  22. Content Article
    Behaviour Change Techniques are the ‘active ingredients’ of activities that lead to behaviour change. These cards were developed by Lucie Byrne-Davis, Eleanor Bull and Jo Hart to help those who work with people to try to change their behaviour, and particularly for educators, trainers, leaders and those involved in organisational development, quality improvement or implementation. This was was funded by Health Education England
  23. Event
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    Join this 90-minute webinar to hear latest updates on workplace health and safety standards from the NHS Staff Council's Health, Safety and Wellbeing Group, and how these can be implemented to best support your workforce. The standards pull together legal requirements and guidance to help NHS organisations comply with goal-setting legislation. They provide practical pointers and signposting for meeting the appropriate standards and legal duties in key areas of workplace health and safety. The webinar will be hosted by Jenny Michael and Kim Sunley, co-chairs of the NHS Staff Council’s Health, Safety and Wellbeing Group. Attendees will also hear from the Health and Safety Executive on key findings and recommendations from its recent inspection activity, and from the assistant director of health and safety at Liverpool University Hospital NHS Foundation Trust. Register
  24. News Article
    Exploitative and “underhand” marketing of formula milk is preventing millions of women from breastfeeding, according to a series of reports published in the Lancet. The reports, by 25 experts from 12 countries, including paediatricians, public health specialists, scientists, economists and midwives, finds that the commercial milk formula companies “exploit parents’ emotions and manipulate scientific information to generate sales at the expense of the health and rights of families, women and children”. Breastfeeding promotes brain development, protects infants against malnutrition, infectious diseases and death, while also reducing risks of obesity and chronic diseases in later life. It also helps protect mothers against breast and ovarian cancers. The World Health Organization (WHO) recommends exclusively breastfeeding babies for the first six months and giving breast milk alongside solid food until the age of two or beyond. Over three reports, the series reveals how, more than 40 years since the World Health Assembly developed a voluntary international code prohibiting the marketing of infant formula, widespread violation of the code persists, with promotion of infant formula milk continuing in about 100 countries in every region of the world since the code was adopted. Read full story Source: The Guardian, 7 February 2023
  25. News Article
    Millions of people in England with mental ill-health are not seeking NHS help, and many who get it face long delays and a “poor experience”, a report says. Long waits for care will persist for years because soaring demand, exacerbated by Covid, will continue to outstrip the ability of severely understaffed mental health services to provide speedy treatment, the National Audit Office (NAO) found. The report found that “NHS mental health services are under continued and increasing pressure and many people using services are reporting poor experiences”. Under-18s, the LGBT+ community, minority ethnic groups and people with more complex needs are most likely to find the system inadequate. “While funding and the workforce for mental health services have increased and more people have been treated, many people still cannot access services or have lengthy waits for treatment,” the NAO said. It found: An estimated 8 million people with mental health needs are not in contact with NHS services. There are 1.2 million people waiting for help from community-based mental health services. While the mental health workforce grew by 22% between 2016-17 and 2021-22, the NHS recorded a 44% increase in referrals over the same period. In 2021-22, 13% of mental health staff quit. Read full story Source: The Guardian, 9 February 2023
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