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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
    This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-1-day-masterclass or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.
  2. Event
    This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-1-day-masterclass or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.
  3. Event
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    The NHS England National Patient Safety Team are hosting two workshops to support Integrated Care Boards to prepare to transition to the new Patient Safety Incident Response Framework (PSIRF). The workshops will be held across two dates Monday 16 January 2023 and Tuesday 17 January 2023 to create smaller group sizes for discussion. The content will be the same across both dates. The webinar will cover: Introduction and latest updates on PSIRF. How oversight changes under PSIRF. The new role of the ICB. Working collaboratively with providers. Training requirements. Q&As. Speakers: Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England Lauren Mosely, Head of Patient Safety Implementation, NHS England. Register
  4. Event
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    This Engaging and involving those affected by patient safety incidents – exploring different models webinar is part of a practical webinar series from NHS England to support organisations to transition to the Patient Safety Incident Response Framework (PSIRF). Following the PSIRF preparation guide, this webinar focuses on the question from the ‘Discovery and diagnostic’ phase - ‘How do you engage and involve those effected by patient safety incidents?’ The agenda includes: Update from the national patient safety team. Designing systems and processes to meet the requirements of the ‘engaging and involving patients, families and staff following a patient safety incident’. Challenges and successes from two providers. Speakers: Tracey Herlihey, Head of Patient Safety Incident Response Policy Lauren Mosley, Head of Patient Safety Implementation Madga Wroblewska-Trojano, Family Liaison Office, Southern Health NHS Foundation Trust Speaker 2: Provider organisation TBC Register
  5. Event
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    This is the second in a series of practical webinars from NHS England to support organisations to transition to the Patient Safety Incident Response Framework (PSIRF). Following the PSIRF preparation guide, this webinar coincides with the transition from the ‘Discovery and diagnostic’ phase, to the ‘Governance and quality monitoring’ phase. The agenda includes: Update from the national patient safety team. Look back at the ‘Diagnostic and discovery’ phase and look forward to the ‘Governance and quality monitoring phase’ with examples of challenges and successes. Speakers: Tracey Herlihey, Head of Patient Safety Incident Response Policy Lauren Mosley, Head of Patient Safety Implementation Dr Tanya Claridge, Acting Group Director of Clinical Governance, Manchester University NHS Foundation Trust Stephen Tipper, Chartered Ergonomist and Human Factors Specialist, Human Factors Programme Manager, University Hospitals Coventry and Warwickshire NHS Trust Register
  6. Event
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    The Covid-19 pandemic has laid bare deep-seated health inequalities and the issue is now at the forefront of the minds of people across the health and care system, as they seek to develop strategies aimed at reducing health inequalities at a regional, integrated care system (ICS) and place level. This conference will bring together individuals and teams developing health inequalities strategies. We will discuss the need for universal action at a population health level and targeted action to address issues affecting people facing the worst health outcomes, showing how these two approaches interlink. The conference will also explore opportunities across health and care to tackle health inequalities and learn from local and international leaders about how they are overcoming the challenges of turning evidence into action to make a difference to health inequalities. Register
  7. Event
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    This conference from the Westminster Health Forum will focus on the future for diagnostics and medical devices in England - looking at developments and next steps for strategy and regulation. The discussion takes place in the context of the upcoming MedTech strategy from DHSC, and will be an opportunity to examine priorities for improving flexibility and transparency in MedTech supply and procurement, securing value for money, and supporting the adoption of innovation in healthcare settings. Delegates will discuss implementation of the MHRA update to the regulation of medical devices, as well as priorities for safety, assessment and contribution to better patient outcomes. Overall, areas for discussion include: Regulation and evaluation: transition to the new medical device regulations and the updated evaluation process - implementation of the new MHRA medical device regulation proportionate regulation and support for businesses - addressing capacity constraints of authorisation of Approved Bodies patient access: establishing new device frameworks for supporting adoption of innovative medical technology - supporting patient access to devices currently on the market the supply chain: flexibility, transparency and responsiveness in the procurement and supply of medical technology collaboration between healthcare providers and suppliers - engaging healthcare professionals in procurement. Supporting the NHS: workforce efficiency and earlier diagnosis - innovation in diagnostic pathways to address backlogs and wait times - improving patient outcomes and the speed of recovery the role of the new community diagnostic centres - encouraging adoption of new diagnostic methods in the centres and across the NHS. Register
  8. Community Post
    A new blog, published on the hub, tells the story of Jenny who passed away from pulmonary embolism, having been misdiagnosed. Her son Tim is campaigning for improvements in pulmonary embolism awareness and care to reduce the risks of misdiagnosis. Have you, or someone you know, been affected by a pulmonary embolism? Was there a misdiagnosis? Please share your experiences, and thoughts on Tim's blog, in the comments below. You'll need to be a hub member to comment below, it's quick and easy to do. You can sign up here.
  9. News Article
    All new hospitals built in England must have only single patient rooms, health infrastructure chiefs have confirmed, requiring an overhaul of many trusts’ current proposals. Leaders of the New Hospitals Programme said the NHS needed to be “brave”, with the move marking an end for multi-bed bay wards and representing a major change in hospital design. Previously, NHS trusts were expected to consider a minimum of 50% single rooms when refurbishing or building new facilities, but HSJ revealed in September that officials were considering a 100 per cent requirement. Natalie Forrest, senior responsible officer for NHP, said England was “behind the times” on single patient rooms. She said: “If we really want to look for evidence of why patients should have the ability to sleep in privacy and choose to socialise in social areas… we need not look very far. Scotland, Wales, Ireland, Europe, the US – where they wouldn’t dream of building a hospital that didn’t provide single bedroom occupancy.” Ms Forrest, who is also a nurse, acknowledged an “anxiety” among NHS staff that they can’t care for patients in single rooms as well, and stressed the need to combine them with “digital technology”. “I have said we need to be brave and take on new challenges, and this is one of those brave decisions the NHS needs to stand up and move forward with.” Read full story (paywalled) Source: HSJ, 13 December 2022
  10. News Article
    Increasing numbers of emotionally troubled children have been taken into care while waiting long periods for NHS treatment because their condition deteriorated to the point where their parents could no longer cope with their behaviour, child protection bosses have revealed. Association of Directors of Children’s Services (ADCS) president Steve Crocker said that since the pandemic, youngsters with complex emotional needs had become a significant factor in rising child protection referrals. “We are seeing children in the social care system because they have not been supported in the [NHS] mental health system,” he said. Crocker urged ministers to “do better” for children facing “unacceptable” delays in NHS mental health treatment, adding that it was not uncommon for waiting lists to involve waits of over a year. Councils were “filling gaps” in NHS provision but struggling to find placements for children with severe behavioural problems, and when they did, typically paid “untenable” fees of tens of thousands of pounds a week. He accused private children’s residential care providers and their “rapacious” hedge fund backers of “profiteering” from the care crisis, and urged the government to intervene to cap typical profit margins that were currently about 20%. “We do not see how this can be allowed to continue,” he said. Read full story Source: The Guardian, 13 December 2022
  11. News Article
    Medics and nurses have been urgently called upon to support London Ambulance Service during next week’s strike action, as it will otherwise have to rely on staff only able to provide ‘first aid’. The North East London primary care team has sent out a request for clinical staff working for integrated care boards to be released from duties ahead of industrial action on 21 December. Unison members are preparing to walk out, alongside thousands of other staff at nine other ambulance trusts across the country, in a dispute over pay. The letter, seen by HSJ, was sent yesterday afternoon. It said: “LAS are keen to have experienced medics and nurses, who have current urgent and emergency clinical exposure, have knowledge of how to navigate the system and can operate as a senior clinical decision maker. Medical Practitioners would ideally be from general practice and emergency medicine. “Advanced Paramedics and Advanced Care Practitioners with urgent care or IUC CAS experience are also required. A knowledge of ambulance services is preferred as it removes the need to learn very quickly the significant differences in ambulance services and LAS control rooms." Read full story (paywalled) Source: HSJ, 13 December 2022
  12. News Article
    The family of a boy who died of an invasive form of strep A have said they sought medical help three times before he was admitted to hospital. Jax Albert Jefferys, who attended Morelands Primary School in Waterlooville, Hampshire, died on 1 December, aged five. His family said they were initially told he had flu. Since September, UK Health Security Agency figures show 15 UK children have died after invasive strep A infections. Paying tribute to their "darling son", Jax's family said they had sought medical advice on three occasions during the four days leading up to his death and were told that he was suffering with influenza A. "We then followed the recommended course of action: to administer a proprietary paracetamol-based medication in the prescribed dosage," they said in a statement. However, they said on the fourth day Jax's condition "deteriorated so much" they "rushed him to hospital" and he later died. "Only after his death was it confirmed that the cause was [strep A]," the family said. Read full story Source: BBC News, 14 December 2022
  13. Content Article
    Jenny Edwards died in February 2022 from pulmonary embolism, following misdiagnosis. In this blog, her son Tim introduces us to Jenny, illustrating the deep loss felt following her premature passing. He talks about the care she received and argues that there were multiple points at which pulmonary embolism should have been suspected. Tim found the investigation that followed Jenny’s death to be lacking in objectivity and assurance that any learning could be taken forward. He has since produced an independent report, drawing on existing data, freedom of information requests and his mother’s case, to highlight broader safety issues.
  14. News Article
    All ambulance services have declared the highest level of alert due to ‘extreme pressures’ facing the urgent and emergency care system. One senior ambulance chief told HSJ that ambulance response times have dropped dramatically in the last few days, while A&E handover delays have surged. They said: “The wheels are falling off [the emergency care system] now, we’re in a really awful situation.” They said ambulance leaders have major concerns about the planned strike action by nurses on Thursday, fearing this will exacerbate discharge delays and have a knock-on effect on ambulance handover problems. It also comes ahead of strike action planned by ambulance staff for next week. HSJ has seen internal communications which confirm all ten ambulance trusts in England are now in level four of their “resource escalation action plan”, which means they can seek assistance from other nearby trusts or services. However, this is more difficult when an entire sector is under pressure, as is the case currently. Read full story (paywalled) Source: HSJ, 13 December 2022
  15. News Article
    Autistic people in England who do not also have a learning disability are approximately 51% more likely to die in a single year compared to the general population, according to a leaked document which estimates the mortality rate for the first time. According to an internal NHS England document, seen by HSJ, the standardised mortality rate between April 2020 and March 2021 was 16.6 deaths per 10,000 for people with autism and no learning disability compared to 11 deaths per 10,000 for the general population. NHSE also determined life expectancy for this group to be 75 years – 5.4 years less than the general population. Dominic Slowie, former national clinical director for learning disability, told HSJ that because of the different ways autism presents itself, it can be difficult to pinpoint causes of premature mortality. “In some cases, people with autism who are severely disabled and can’t communicate their needs in a conventional way are going to have premature mortality for the same reasons that people with a learning disability do, because people do not really understand the level of their need or do not investigate their need in a reasonably adjusted way,” he said. “While, if someone is presenting atypically in their communication, we mustn’t make presumptions – we must make reasonable adjustments to ensure they are investigated and diagnosed in the same way.” Read full story (paywalled) Source: HSJ, 13 December 2022
  16. News Article
    Lucy Letby used a plunger to force milk and air into one of the babies she is accused of attempting to murder, a medical expert has told a court. The alleged attack caused the infant’s stomach to distend to such a degree that she then projectile vomited a “massive” amount of milk so violently that the material left her cot and splashed over a chair several feet away. Staff at the Countess of Chester Hospital managed to save Baby G’s life but the incident was so catastrophic that it caused the child severe brain damage. Seven years later she still suffers from quadriplegic cerebral palsy. Dr Dewi Evans, a consultant paediatrician called in by the prosecution, said the use of a plunger on the end of a syringe was the only explanation for the baby’s sudden collapse in the early hours of 7 September 7 2015. Letby, 32, of Hereford, is accused of murdering seven children in the neonatal unit of the hospital in Cheshire, and of ten attempted murders, between June 2015 and June 2016. She denies all the charges. Read full story (paywalled) Source: The Times, 13 December 2022
  17. Content Article
    This policy paper, published by the Department of Health and Social Care, provides an update on the UK Government’s progress in implementing the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review, sometimes referred to as the Cumberlege Review.
  18. News Article
    The number of operations cancelled by the NHS in England because of staff shortages may have doubled in three years, with an estimated 30,000 not proceeding because no staff were available to perform them. At least a third of cancelled operations were those that were deemed urgent, according to the analysis by Labour. It suggested at least 2,500 cancelled operations for cancer patients and 8,000 on children. It found staff shortages were the most common reason given for cancellations by hospitals, accounting for one in five of all operations cancelled for non-clinical reasons last year. The Department of Health and Social Care said it was “misleading” to extrapolate that figure from the data in the FOIs. “Thousands of elective appointments and procedures had to be cancelled during the pandemic to protect the NHS, and since then we’ve been focused on delivering the biggest catch-up programme in health history - virtually eliminating the longest 2-year waits for treatment,” a spokesman said. In total, 158,000 operations were cancelled for issues including equipment failures, a shortage of beds, and 5,700 because of equipment failure, administrative errors, and theatre lists overrunning. Labour cited one case that involved a 72-year-old woman who had two operations to remove a brain tumour cancelled in September, blamed on a lack of available beds. About 9,500 operations were cancelled because an emergency case took priority, and 250 due to adverse weather. Separate figures from the NHS show record numbers of operations cancelled at the last minute are not rearranged to take place within a month, with one in five patients waiting longer. Read full story Source: The Guardian, 12 December 2022
  19. News Article
    Bosses at the North West Ambulance Service issued an urgent warning to members of the public on 999 calls and apologised for delays last night. At 5pm on Monday (December 12), more than 600 patients were waiting for an ambulance across the North West, the service said. Another 100 emergency vehicles were parked outside of hospitals waiting to handover patients. 'Severe weather and hospital handover delays' had an impact on the service last night, as well as 'significant demand'. Ambulance chiefs said they had to 'maximise resources' by putting all clinically-trained staff on the frontline and increasing use of private providers. In an urgent message issued on Monday night, medical director Dr Chris Grant said: "This is an urgent message for the public across the whole of the North West. Tonight, across both our 111 and 999 services, we're seeing a really significant demand and I apologise for the delay in getting care to you but I do need your help. "We've called in all our operational and clinical resources to make sure we prioritise those who have the most life-threatening conditions. We need to keep our phone lines free so please only call us back if you no longer need our help or if your own condition has got significantly worse. Thanks for your support." Ged Blezard, director of operations at NWAS said: "Please only call 999 if someone has a serious illness or injury, you think their life is at risk, and you cannot get them to hospital by any other means. We know there are patients waiting for our help and we are sorry that we are unable to respond as quickly as we would like. Read full story Source: Manchester Evening News, 13 December 2022
  20. News Article
    A “decade of neglect” by successive Conservative administrations has weakened the NHS to the point that it will not be able to tackle the 7 million-strong backlog of care, a government-commissioned report has concluded. The paper by the King’s Fund says years of denying funding to the health service and failing to address its growing workforce crisis have left it with too few staff, too little equipment and too many outdated buildings to perform the amount of surgery needed. The UK’s poor public finances, health service staff suffering from exhaustion, and a wave of NHS strikes this winter will also lead to ministers being unable to deliver key pledges on eradicating routinely long waits, the thinktank says. “Though Covid certainly exacerbated the crisis in the NHS and social care, we are ultimately paying the price for a decade of neglect,” said the King’s Fund chief executive, Richard Murray. “The sporadic injections of cash during the austerity years after 2010 were at best meant to cover [the service’s] day-to-day running costs. This dearth of long-term investment has led to a health and care system hamstrung by a lack of staff and equipment and crumbling buildings. These critical challenges have been obvious for years. “The NHS in 2022 faces many of the same challenges it faced in 2000: unacceptably long waiting times and a service hobbled by staff shortages. To that is now added a cost of living crisis, industrial action by staff and a backdrop of a weak economy and weak public finances.” Read full story Source: The Guardian, 12 December 2022
  21. Content Article
    In the face of record high waiting times for elective care, The King's Fund undertook research to understand the strategies that have been used to reduce waiting times in England and elsewhere in the past 20 years. Elective care waiting lists and waiting times are a product of the fluctuations in and disparities between the demand for and available supply of healthcare. Understanding the root causes of these disparities and taking corrective action to restore balance between demand and supply and optimising the conditions within the health care system is therefore considered key to any strategy to reduce waiting times and sustain them at that level.
  22. News Article
    A man who had broken his hip was taken to hospital strapped to a plank in the back of a van after his granddaughter was told no ambulances were available. Nicole Lea found Melvyn Ryan behind the door of his home after he pressed an emergency call button around his neck. When she got there she discovered the 89-year-old also had a broken shoulder. She said she went to grandfather-of-eight Mr Ryan's home, in Cwmbran, Torfaen, after being contacted just after midnight on Friday. She said: "I didn't waste any time in calling 999 and gave them my details. And they turned around and said they were unable to send anyone, there wasn't any help to send and that I'd have to find a way of getting him there myself." The call handler advised her to call the out-of-hours GP before saying she had to go to deal with other calls. She did not call the GP as she thought it would be a waste of time. "With my partner and my mum's help we managed to come up with the idea of getting him onto a plank of wood and into the back of my partner's van to get him up to hospital," Ms Lea said. "Mr Ryan has had what sounds like the most appalling of experience," said Dr Iona Collins, chairwoman of the British Medical Association (BMA) Cymru. "How must the ambulance service feel when they are getting calls like this? Obvious its an emergency and they need help and they are unable to help," she told Radio Wales Breakfast. Read full story Source: BBC News, 12 December 2022
  23. News Article
    English hospitals have increased emergency fuel supplies and put staff on standby to postpone operations and switch off X-ray scanners amid heightened concerns over energy provision this winter. NHS hospital trusts across England have put their power plans under the microscope as they look to protect patients from potential outages for lifesaving equipment. Responses to freedom of information requests to 63 NHS trusts revealed that 41 are re-examining their plans for a loss of power for this winter. A further 10 trusts said they conducted routine reviews of their business continuity plans this year, while 12 had not revised their strategies. National Grid warned in October that, in extreme circumstances, it would be forced to enact planned three-hour power cuts with a days’ notice. Major hospitals are exempt from this system, called rota disconnection, however businesses and the government have studied their plans for a complete power failure on the network. Despite the pressure on the NHS budgets, the responses show that most hospitals have up-to-date plans and backup generators to ensure lives are not lost due to lack of power. A quarter of hospital trusts said they were able to run indefinitely on backup diesel generator power, providing they had access to fuel supplies. Just over 10% said they could run on backup power for 10 days. Read full story Source: The Guardian, 12 December 2022
  24. Content Article
    Fundamentals of Health Care Improvement: A Guide to Improving Your Patient’s Care, 4th edition, is intended to help health professional learners diagnose, measure, analyse, change and lead improvements in healthcare, with the aim to shape reliable, high-quality systems of care in partnership with patients. Copublished by Joint Commission Resources and the Institute of Healthcare Improvement, this fourth edition includes updated resources, including examples, figures, tables, and tools. New to this edition is a focus on health equity and disparities of care brought to light by the COVID-19 pandemic. This focus explores the relationship between social determinants of health and how improvement methods and skills can help identify and close disparity gaps in systems of care. Also new to this edition is an expanded discussion of effective teamwork and the importance of creating multidisciplinary health care teams that partner with patients and families.
  25. News Article
    A new survey of more than 1,000 surgeons across the USA reiterates concerns that impending cuts to surgical care, set to take effect on 1 January 1 2023, will lead to a decrease in Medicare patient intake, increased delays to care, and longer wait times for patients in surgical practices. These survey results support the efforts of the over one million physician and non-physician healthcare providers joining together in urging congressional leadership to stop the full cut to Medicare payments through a Week of Action. "Our survey results confirm that the impending cuts to Medicare payments will be disastrous for patients and their access to life-saving and life-altering care," said Patricia L. Turner, American College of Surgeons Executive Director and Chief Executive Officer. "As our population continues to age, more and more seniors depend on Medicare to receive the care they need. Congressional leadership must protect patients by stopping the full cut to Medicare payments so healthcare providers can focus on delivering high-quality care to patients." The survey, conducted for the American College of Surgeons, a founding member of the Surgical Care Coalition, found: Around two-thirds of members expect patients will be faced with delays to care (68%) or longer wait times (65%). These are up from 56% and 57%, respectively, in 2021. One-in-three (33%) members say there will be a change in their Medicare patient intake if the cuts were to go into effect, up from 25% in 2021. 20% say they expect to take on fewer new Medicare patients, but that they will keep all existing Medicare patients. While members report feeling the impact from supply chain issues and inflation, surgeons are also sounding the siren around healthcare worker shortages. Over nine-in-ten (93%) report healthcare worker shortages impacting their ability to provide high quality care over the last year. Over three-quarters (77%) report "a great deal of impact" from these shortages. Read full story Source: CISION PR Newswire, 9 December 2022
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