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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Sickle cell patients are being put at risk because of a chronic shortage of specialist nurses to treat them, a damning new report has found. 'The Difference Between Life and Death', a new study by the Sickle Cell Society, found that there are not enough sickle cell workers to deliver a good standard of care. One patient called Abi Adeturinmo told researchers that previous traumatic experiences caused by delays in receiving pain relief medication and poor care meant she “tries not to go to the hospital when in sickle cell crisis unless it is life-threatening”. Another patient, Araba Mensah, whose daughter has sickle cell disorder, said there was a lack of “hands-on” nursing, and said patients who have difficulties feeding themselves or with personal hygiene were “left to suffer unattended”. John James, CEO of the Sickle Cell Society, said: “While there are undoubtedly workforce challenges across all parts of the health system, the evidence in this report suggests that sickle cell is disproportionately impacted as a result of the legacy of neglect of sickle cell care. “On behalf of everyone affected by sickle cell, we are urging NHS England to take action now to ensure all sickle cell patients have access to the specialist care they are entitled to.” Read full story Source: The Independent, 24 November 2023
  2. News Article
    Plans to prevent one of the deadliest cancers for women in Jamaica have been significantly set back by the Covid pandemic, new figures reveal. The scheme to vaccinate schoolgirls against cervical cancer in Jamaica – which is the cancer with the second highest death rate in the Americas – began in 2018, but the Pan American Health Organization says inoculation rates fell to just 2.71% in 2021. This represents a drastic drop from the 2019 rate of 32%, and far from the WHO target of 90% by 2030. The cancer, which is curable if caught early, kills 22 in every 100,000 women in Jamaica. By comparison, in the UK the rate is 2.4 in every 100,000, and in Canada it is 2. Prevention of cervical cancer in Jamaica is also hindered by low rates of cervical screenings. “Women are afraid of the screening process and potential pain, but there is also a fear of a cancer diagnosis itself,” said Nicola Skyers of Jamaica’s Ministry of Health. “Some people just prefer not to know. But I also think that healthcare providers don’t offer screenings often enough. If a healthcare provider is really ‘selling’ the pap smear, more often than not the woman will choose to have it.” Health workers are forced to focus on cures rather than preventions amid staffing shortages and an overburdened healthcare system, said Skyers. “As a doctor, you won’t be encouraging every women you see to do a pap smear if you have 40 patients waiting outside.” Read full story Source: The Guardian, 2 February 2023
  3. News Article
    President Joe Biden has announced to the US Congress that he will end the country’s Covid-19 public health emergency on 11 May, although about 500 Americans are currently dying every day from Covid-19. He also plans to end the related national Covid-19 emergency. In contrast, the World Health Organization said on 27 January that the Covid-19 pandemic was still a public health emergency. The US administration’s statement said that extending the emergencies until May would provide time for an orderly transition. Ending the emergencies will mean that many Americans will lose the health insurance provided through the Medicaid programme, which helps people on low incomes and was extended during the pandemic. Many others will find that they no longer get free tests, treatments, or vaccines. Read full story Source: BMJ, 1 February 2023
  4. News Article
    Commissioners have begun a ‘serious incident review’ across their integrated care system after early indications showed patients may have suffered harm due to long waits for cancer treatment. The review has been launched by Somerset Integrated Care Board into dermatology services after an initial review found five of 50 patients had seen their skin lesions increase in size since being referred to hospital by their GPs. ICB board papers stated “potential patient harm has been identified” for those patients, who were on the two-week wait pathway to be seen by a specialist following a referral by their GP. Read full story (paywalled) Source: HSJ, 3 February 2023
  5. News Article
    Every year, millions of people live fuller lives because of a medical device implanted somewhere in their body - from hip joints, to teeth, to heart valves. Known as Foreign Body Response (FBR), inflammation and scarring around an implant is natural, but in some cases, it can severely damage healthy tissue and can even lead to death if the implant is not removed. FBR-related implant failure rates range widely among different medical devices, but reducing those rates has been difficult because scientists still don’t understand the underlying biology that causes FBR. Now, researchers from the University of Maryland have discovered the molecular basis for FBR, identifying a key biological pathway that future drug therapies could target to reduce the risk of implant rejection. Shaik O. Rahaman, an associate professor in the Department of Nutrition and Food Science in the College of Agriculture and Natural Resources at UMD, and his colleagues identified a specific cellular signaling system that kicks in when the body recognises the inherent difference in stiffness between an implant and the surrounding tissue. This system detects the mismatch and triggers inflammation and scarring, which is part of the body’s normal defense system. But in FBR, the signaling system can set up a cycle of chronic inflammation and continual scar-tissue build-up that leads to implant rejection. “This is a huge leap forward in this field,” Rahaman said. “So far, the medical industry has been making biomedical implants randomly, out of materials they think might work without knowing the molecular basis of the foreign body response that leads to rejection. We don’t know why it happens, and until we do, we can’t effectively develop strategies to prevent it.” Read full story Source: College of Agriculture and Nature Resources, 19 January 2023
  6. News Article
    Mesh campaigners claim Scotland's Health Secretary Humza Yousaf refused to meet them to hear their concerns. Patients blame surgical mesh products for leaving them disabled and in chronic pain and want the Scottish Government to hold an independent review into the use of the products. However, followihttps://www.dailyrecord.co.uk/news/mesh-campaigners-claim-humza-yousaf-29075491ng a debate in the Scottish Parliament earlier this month, the Health Secretary denied their request. Campaigner Roseanna Clarkin, of the Scottish Global Mesh Alliance, said Yousaf has refused several requests for meetings with campaigners spanning nearly two years. Roseanna, who has been left with crippling pain after mesh was used on her umbilical hernia in 2015, has blasted him for “ignoring” those affected by mesh procedures. From the late 90s until 2018, women in Scotland were treated with polypropylene mesh implants for stress urinary incontinence and pelvic organ prolapse. In some, it caused severe pain and life-changing side effects. While the Independent Medicines and Medical Devices Safety Review called for a pause in use of vaginal mesh, the products are not banned for all procedures. The Scottish Global Mesh Alliance were behind the petition calling for an independent review which was debated at Holyrood. They want to suspend the use of all surgical mesh and fixation devices while a review is carried out. Roseanna said: “Why do they assume mesh in another part of the body would respond differently and not cause extreme pain and serious infections?” Read full story Source: Daily Record, 29 January 2023
  7. News Article
    Patients across the UK are set to benefit from access to safe, effective and innovative equipment and medical devices as part of the first ever medical technology (medtech) strategy published today. The blueprint for boosting NHS medtech will focus on accelerating access to innovative technologies, such as the latest generation of home dialysis machines that enable patients to manage their own health at home and in their day to day lives. It also sets out steps which need to be taken to ensure patients can access safe, effective and innovative technology through the NHS, which can help diagnose, treat and deliver care more quickly, freeing up clinician time. The NHS spends £10 billion a year on medtech including syringes, wheelchairs, Minister of State for Health Will Quince said: "The UK’s innovative spirit delivered revolutionary technology during the pandemic - from COVID tests and ventilators - and we want to harness this in promoting cutting-edge medical advancements to improve patient care. The NHS spends around £10 billion a year on medical technology and I’m looking forward to working with industry to use this as we focus on reducing hospital stays, enhancing diagnosis, preventing illness and freeing up staff time. This new medtech strategy will help build a sustainable NHS with patients at the centre so people can continue to access the right care at the right time." The key aims of the strategy are to: boost the supply of the best equipment to deliver greater resilience to health care challenges, such as pandemics, and enhance NHS performance through modernised technology which will enable faster diagnosis, treatment and ultimately discharge to free up hospital beds. encourage ambitious, innovative research to secure the UK’s position as a global science superpower and attract vital investment for the UK economy and create jobs across the country. In 2021, there were already around 60 different research programmes supporting innovative technologies, representing over £1 billion of funding. increase understanding and awareness of medtech by clinicians which will lead to more informed purchasing on new products and deliver better value for taxpayer money and better services for patients. build on the Life Sciences Vision to improve collaboration between the NHS, the National Institute for Health and Care Excellence (NICE) and the Medicines and Healthcare products Regulatory Agency (MHRA) as an innovation partner to ensure patients can access the right products safely. Read full story Source: DHSC, 3 February 2023
  8. Content Article
    Medical technology, or ‘medtech’, is of vital importance to the UK health and care system. The Government's first Medical technology strategy outlines how it will ensure the health and social care system can reliably access safe, effective and innovative medical technologies that support the continued delivery of high-quality care, outstanding patient safety and excellent patient outcomes in a way that makes the best use of taxpayer money.
  9. Content Article
    The purpose of this assessment is to ensure that all Theatre Practitioners are fully compliant with current Trust Policy with regard to swabs, instruments, sharps and disposables items. All Theatre staff must be assessed and deemed competent.
  10. Content Article
    The original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. Understanding of how to deliver safe care in a complex and pressurised system is evolving. These revised standards (NatSSIPs2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care. The Centre for Perioperative Care shares their slideset on the revised standards.
  11. News Article
    More than 500,000 people in the UK will be diagnosed with cancer every year by 2040, according to analysis by Cancer Research UK. In a new report, researchers project that if current trends continue, cancer cases will rise by one-third from 384,000 a year diagnosed now to 506,000 in 2040, taking the number of new cases every year to more than half a million for the first time. While mortality rates are projected to fall for many cancer types, the absolute numbers of deaths are predicted to increase by almost a quarter to 208,000. In total, it estimates that between 2023 and 2040, there could be 8.4m new cases and 3.5 million people could have died from cancer. Cancer Research UK’s chief clinician, Charles Swanton, said: “By the end of the next decade, if left unaided, the NHS risks being overwhelmed by the sheer volume of new cancer diagnoses. It takes 15 years to train an oncologist, pathologist, radiologist or surgeon. The government must start planning now to give patients the support they will so desperately need.” Read full story Source: The Guardian, 3 February 2023
  12. Content Article
    Ahead of World Cancer Day 2023, Cancer Research UK have published a new report that shows that the impact of cancer for people in the UK will only grow, and sets out the challenges that cancer services are already facing today. New modelling published in the report, Cancer in the UK: Overview 2023 shows that if current trends continue, cancer cases will rise from the 384,000 diagnosed each year now, to over half a million by 2040. To put that into context, that means around a third more people will be diagnosed with the condition every year in comparison to current levels. And we could see around a quarter more annual cancer deaths – 208,000 by 2040, With services barely treading water now, Governments across the UK must act if they are to effectively meet the increase in demand that this analysis anticipates, but efforts have been piecemeal so far.
  13. News Article
    Nurse Lucy Letby sent a sympathy card to the grieving parents of a baby girl just weeks after she allegedly murdered the infant, a court has heard. She is accused of trying to kill the premature baby, referred to as Child I, three times before succeeding on a fourth attempt on 23 October 2015. She denies murdering seven babies and attempting to murder 10 others. Manchester Crown Court was shown an image of a condolence card Ms Letby sent to the family of Child I ahead of her funeral on 10 November. The card was titled "your loved one will be remembered with many smiles". Inside, Ms Letby wrote: "There are no words to make this time any easier. "It was a real privilege to care for [Child I] and get to know you as a family - a family who always put [Child I] first and did everything possible for her. "She will always be part of your lives and we will never forget her. "Thinking of you today and always. Lots of love Lucy x." It is alleged that before murdering Child I, Ms Letby attempted to kill the infant on 30 September and during night shifts on 12 and 13 October. The prosecution said she harmed the premature infant by injecting air into her feeding tube and bloodstream before she eventually died in the early hours of 23 October 2015. Read full story Source: BBC News, 2 February 2023
  14. News Article
    An acute trust has discovered an IT issue which appears to have led to ‘very high’ numbers of patients not turning up for their appointments. Bedfordshire Hospitals Foundation Trust discovered appointment letters were being lost, and not sent to patients, during intermittent server failures, its board was told yesterday. The trust’s “did not attend“ rate has been between 10% and 12% over the last year, compared to the national average of 7%, according to its board papers. The issue relates to patients with appointments booked at Luton and Dunstable Hospital. It is not yet clear how many patients were affected. The trust is now planning to ensure every patient with an appointment booked this year receives a new appointment letter, and an apology if they did not previously receive one. Read full story (paywalled) Source: HSJ, 2 February 2023
  15. News Article
    A long-running public inquiry into what has been called the worst treatment disaster in the history of the NHS will hear its final evidence on Friday. It is thought tens of thousands were infected with HIV and hepatitis between 1970 and 1991 after being given a contaminated drug or blood transfusion. The inquiry, which started in 2018, has reviewed thousands of documents and heard testimony from 370 witnesses. A total of 1,250 people with haemophilia and other bleeding disorders contracted HIV after being given a protein made from blood plasma known as Factor VIII. About half of that group later died of an Aids-related illness. Researchers found that 380 of those infected with HIV - about one in three - were children, including some very young toddlers. One of the key questions the inquiry will now have to answer is whether more could and should have been done to prevent those infections and deaths. Hundreds of victims of the scandal have received annual support payments but - before this inquiry - no formal compensation had ever been awarded for loss of earnings, care costs and other lifetime losses Further recommendations on compensation are expected when the inquiry publishes its final report, which is likely to be around the middle of the year. Read full story Source: BBC News, 3 February 2023
  16. Content Article
    The General Practice Data Trust (GPDT) Pilot Study: Report on Patient Focus Groups reports on patients’ attitudes about sharing their health data for research and planning purposes.  It is the result of research by academics at the Centre for Social Ethics and Policy (CSEP) at the University of Manchester, supported by the Patients Association, and is part of the GP Data Trusts pilot project. Funded by the Data Trusts Initiative, the project wanted to understand why so many people opted out from NHS Digital’s GP Data for Research and Planning (GPDPR) programme when it was launched in 2021.    The research found that patients mostly supported the use of patient data in health research, but they often didn’t like the idea that companies might make money from the use of their health data. Many felt they had not been given enough information about the GPDPR programme; some would have been happy to share their data if they had known more about the programme.   The researchers also asked focus group participants if holding patient data in a trust would reassure them about how their data are used. This was welcomed and the report goes into more detail about what patients thought of this idea.  
  17. News Article
    Ministers are considering putting a cancer warning on all breast implants a decade after women had ‘a cocktail of chemicals intended for mattresses’ put into their bodies. Experts and MPs are calling for tighter regulation and better support after the PIP faulty breast implant scandal left women – including breast cancer survivors – ‘suffering and dying in silence’. Health minister Maria Caulfield pledged on Monday to consider a so-called ‘black-box’ warning on breast implant packaging like in the US. It came during a debate on the faulty breast implant scandal which saw 47,000 British women given ‘ticking time bomb’ implants made by Poly Implant Prothese (PIP). PIP implants were outlawed in 2010 when they were revealed to be made with substandard silicone and up to six times more likely to rupture. Victims of the scandal have reported a wide range of serious side-effects as experts say they are linked to a raft of health problems including the new form of cancer. Anyone with a PIP implant can officially apply to have it removed by the NHS, but Labour MP Fleur Anderson said: ‘Many applications have been turned down, leaving women with a ticking time bomb in their body. ‘They are unable to afford to get their implants removed privately, are worried that they will rupture further, and are experiencing clear side-effects.’ The MHRA acknowledged the risk of cancer for all breast implants but said PIP implants are not at greater risk than any other. Read full story Source Mail Online, 31 January 2023
  18. Content Article
    Surgical site infections (SSIs) can have a significant impact on patients, their families and healthcare providers. With shortening inpatient periods, the post-discharge element of surveillance is becoming increasingly important. Proactive surveillance, including digital wound images using patient smartphones, may be an efficient alternative to traditional methods for collecting post-discharge surveillance (PDS). The aim of this study was to determine success in patient enrolment and engagement including reasons for non-response, the time for clinicians to respond to patients, SSI rates, and carbon emissions when conducting PDS using patient smartphones.
  19. Content Article
    The Scottish Patient Safety Programme (SPSP) is a national quality improvement programme that aims to improve the safety and reliability of care and reduce harm.  Since the launch of SPSP in 2008, the programme has expanded to support improvements in safety across a wide range of care settings including Acute and Primary Care, Mental Health, Maternity, Neonatal, Paediatric services and medicines safety. Underpinned by the robust application of quality improvement methodology SPSP has brought about significant change in outcomes for people across Scotland. 
  20. Event
    The Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. This workshop will highlight how different organisations are approaching incident response decision making and associated governance processes. Audience: PSIRF webinars are open to everyone to attend, including both NHS and arms length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Lauren Mosley, Head of Patient Safety Implementation, NHS England, Kerry Crowther, Patient Safety Specialist, Cornwall Partnership NHS Foundation Trust Christopher Brooks-Daw, Associate Chief Nursing Officer, North Bristol NHS Trust Register
  21. Event
    until
    Taking place over two days in July, this virtual conference will provide you with the insight and guidance to best manage competing agendas and play an active role in shaping local services Join experts from across the health and care sector and gain the confidence to: navigate the evolving role of primary care in communities take an active role in shaping local services champion the voice of patients in primary care support multidisciplinary teams working to deliver integrated care around the needs of the population at neighbourhood and place level prioritise and support staff mental health and wellbeing to reduce burnout. Register
  22. News Article
    A seismic shift is needed in the way that patients’ and families’ voices are heard, with shared decision-making and patient partnership as the destination, says Patient Safety Commissioner, Dr Henrietta Hughes, on the day the Patient Safety Commissioner 100 Days Report is published. In the report, Henrietta reflects on her first 100 days in this new role. She sets out what she has heard, what she has done and her priorities for the year ahead. "Everyone... has a part to play in delivering safe care – know that you can make a difference by putting safety at the top of your agenda. Introduce patient voices into your governance – in your board meetings, commissioning and contracts meetings, design of strategies, policies and processes, team meeting agendas, annual objectives, appraisals, reviews of complaints and incidents, inspections, and reward and recognition. "I want us to be able to look back in astonishment on the way that we operate now. This is the moment to set a new course with shared decision-making and patient partnership as our destination. Without listening and acting on patient voices, safety will continue to be compromised and patients and families will continue to suffer the consequences of harm." Read full story (paywalled) Source: HSJ, 2 February 2023
  23. Content Article
    In this report, Dr Henrietta Hughes, Patient Safety Commissioner for England, reflects on her first 100 days in this new role. She sets out what she has heard, what she has done and her priorities for the year ahead.
  24. News Article
    Hepatitis B transmission from mothers to babies has been eliminated in England, according to the World Health Organisation (WHO). The WHO elimination target is that less than 2% of babies born to mothers with hepatitis B go on to develop the infection. And data from the UK Health Security Agency (UKHSA) shows the figure for England currently stands at 0.1% The UKHSA said progress had been made in tackling the viral infection, which can cause liver damage, cancer and death if left untreated. A six-in-one vaccine is offered to all babies on the NHS when they are eight, 12 and 16 weeks of age. Health and Social Care Secretary Steve Barclay said: “We are paving the way for the elimination of hepatitis B and C, with England set to be one of the first countries in the world to wipe out these viruses.” Read full story Source: The Independent, 2 February 2023 .
  25. News Article
    The CEO of a troubled trust has said evidence is emerging of ‘massively reduced’ length of stay in a new hospital criticised for being too small. Emergency staff have raised concerns about a lack of space and bed capacity at the new Royal Liverpool Hospital, which opened in October, as services have come under severe pressure this winter. The new building, on a next-door site to the old hospital, has fewer beds, although more have opened elsewhere in the city. In an interview with HSJ, Liverpool University Hospitals Foundation Trust chief executive officer James Sumner acknowledged aspects of the new building have created difficulties, including in relation to accident and emergency configuration and capacity, but added the move’s benefits are beginning to be seen. He said a new care model and single rooms throughout the whole hospital are helping to reduce length of stay, as well as eliminating bed closures due to infection outbreaks. He said: “We’ve got really good evidence of massively reduced length of stay in this new building, [with] about 70 fewer people every day waiting over seven, 14 and 21 days in hospital. Read full story (paywalled) Source: HSJ, 1 February 2023
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