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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Medicine shortages are an “increasing problem” for Australia and antibiotics are among the commonly prescribed drugs currently in short supply, the peak body for general practitioners says. The drugs regulator, the Therapeutic Goods Administration (TGA), said the three most commonly prescribed antibiotics – amoxicillin, cefalexin and metronidazole – are scarce. They are used to treat a range of bacterial infections, including pneumonia and other chest infections, skin infections and urinary tract infections. To see patients through the shortage, the TGA has authorised pharmacists to provide alternative antibiotics without approval from the prescribing doctor. “Importantly, many of these medicines have alternatives available,” the TGA said. “Your pharmacist may be able to give you a different brand, or your doctor can prescribe a different strength or medicine with similar spectrum of activity.” A TGA spokesperson said “most of the antibiotic shortages are caused by manufacturing issues or an unexpected increase in demand”. Dr Nicole Higgins, the president of the Royal Australian College of General Practitioners, said the shortage of certain medicines was “becoming an increasing problem in Australia”. Read full story Source: The Guardian, 12 December 2022
  2. Content Article
    Patient safety incident investigations (PSII) are system-based responses to a patient safety incident for learning and improvement. Typically, a PSII includes four phases: planning, information gathering, synthesis, and interpreting and improving. More meaningful involvement can help reduce the risk of compounded harm for patients, families and staff, and can improve organisational learning, by listening to and valuing different perspectives.
  3. Content Article
    Social media can be a fascinating part of the medical world—an intriguing cocktail of joyousness and apathy, good and dark intentions, facts and counter facts. To some, this is something to be dismissed easily. Yet, over time and with easier access to the internet, social media platforms have also become places of dynamism and activism, where things can happen a lot more quickly than in traditional systems, writes Partha Kar, consultant in diabetes and endocrinology, in this BMJ opinion piece.
  4. News Article
    Dilapidated mental health facilities across the country are in need of £677m worth of repairs to fix sewerage issues, collapsing roofs and wards that deprive patients of their dignity, The Independent has been told. An NHS analysis of the government’s flagship programme to build 40 hospitals, seen by The Independent, shows ministers have failed in their promise of “parity” for mental health services as issues are not addressed. NHS trust and psychiatry leaders warned that the out-of-date buildings are putting patients at risk and urged the government to include six mental health hospitals within its next round of improvements. Data analysis by the Royal College of Psychiatrists, shared with The Independent, found that the cost of fixing “high and significant” risks in mental health and learning disability hospitals has rocketed from £92m in 2019-20 to £186m in 2021-22 – far higher than the 16 per cent increase in costs seen in acute hospitals. These are risks that must be fixed to avoid “catastrophic” failure or safety problems that could result in serious injury. Saffron Cordery, interim chief executive at NHS Providers, said patients and staff are at risk because so many buildings aren’t fit for purpose, and warned that things will get worse until mental health trusts get the capital funding they need. Read full story Source: The Independent, 11 December 2022
  5. News Article
    Strep A home-testing kits have sold out online as parents rush to find ways to diagnose their children’s rashes and high temperatures. The panic-buying follows the deaths of at least 16 children from invasive strep A infections in the UK. As infections and deaths from strep A have risen over the past few weeks, parents have turned to tests that involve a long cotton swab that is lightly passed over the back of the throat. Solutions and a strip test are then used to display results. These tests are now being sold online for more than £100, while some retailers have reported selling out after demand soared over the past few days. Other suppliers have warned customers that they will not be able to get hold of a test until after Christmas. One online retailer told customers that they would not be able to get the products until mid-January. Others said they were awaiting deliveries but “there may be delays beyond our control”. Strep A tests are not sold in England through the NHS because the National Institute for Health and Care Excellence (NICE) – which approves and advises on clinical care – has said their accuracy is uncertain and likely to be “highly variable”. Scotland has not approved them either, though in Wales people can buy them over the counter for £7.50. “We’re not advising using those [tests] for the time being,” Professor Kamila Hawthorne, chair of the Royal College of GPs, said on Friday. “It is a clinical diagnosis. It is not too difficult to make. So long as the parent watches their child and brings their child in, then we are more than happy to see them.” Read full story Source: The Guardian, 11 December 2022
  6. News Article
    Six NHS staff workers are typically reported every week in England for sexually harassing a patient or colleague, the Telegraph can reveal. Nearly a fifth of English trusts have recorded a rise in reports of sexual harassment within their services since 2017, while millions have been spent by the NHS on legal claims specific to sexual abuse over the same time period, according to newly obtained data. Health secretary Steve Barclay described the findings as “worrying” and urged NHS leaders to take “robust action in response to any such incidents in their organisation”. Patient Safety Learning said the Telegraph's “deeply troubling” revelations demonstrated an abuse of the “significant power imbalance” that exists between vulnerable patients and their care providers. “Healthcare professionals need to recognise the power they hold over patients,” said chief executive Helen Hughes. “Inappropriate behaviours undermine trust in healthcare system and the ability to deliver safe care.” “Clinicians, managers and healthcare leaders have both a professional and moral responsibility to patients to ensure that there is a safe culture in healthcare settings and that misconduct is not tolerated," said Ms Hughes. As part of its investigation into sexual harassment within the NHS, the Telegraph uncovered the case of a mentally incapacitated patient who was raped by her healthcare worker and subsequently fell pregnant. The healthcare worker, who is in his 30s, was recently jailed for eight months after pleading guilty to sexual activity with a mentally disordered female. Joe Matchett, an expert lawyer at Irwin Mitchell who has secured settlements for survivors of abuse, said his firm continues to “represent a number of patients subjected to terrible abuse at the hands of hospital staff who have betrayed their position of trust in the worst imaginable way”. Read full story (paywalled) Source: The Telegraph, 11 December 2022
  7. News Article
    Hospitals in England have paid out as much as £5,200 for a shift by a doctor through an agency, according to figures obtained by Labour through Freedom of Information requests. That is the latest in an intensifying debate over workforce shortages in the NHS in England. Labour blamed the high agency fees on Conservatives, arguing they had failed to train enough doctors and nurses. A Conservative spokesperson said "record numbers" had been recruited. The most expensive reported shift was £5,234 - paid by a trust in northern England. This covers the agency fee and other employer costs as well as the money going to the doctor. The NHS Confederation said the "staffing crisis" was so "desperate" that NHS trusts were being forced to pay large fees to make sure rotas were "staffed safely". Matthew Taylor, chief executive of the NHS Confederation, said: "Trusts are having to breach the caps on how much they pay for agency doctors because of the extremely high levels of demand they are facing for their services. "The staffing crisis is so desperate that they either pay these fees or find that their rotas cannot be staffed safely, leading to reduced services for patients. This is particularly true in parts of the country where the NHS can struggle to recruit new staff." Read full story Source: BBC News, 12 December 2022
  8. News Article
    More than 1000 investigations have been launched in Scotland over the past decade into adverse events affecting women and infants' healthcare. Figures obtained by the Herald show that at least 1,032 Significant Adverse Event Reviews (Saers) have been initiated by health boards since 2012 following "near misses" or instances of unexpected harm or death in relation to obstetrics, maternity, gynaecology or neonatal services. The true figure will be higher as two health boards - Grampian and Orkney - have yet to respond to the freedom of information request, and a number of health boards reported the totals per year as "less than five" to protect patient confidentiality. Saers are internal health board investigations which are carried out following events that could have, or did, result in major harm or death for a patient. Major harm is generally classified as long-term disability or where medical intervention was required to save the patient's life. They are intended as learning exercises to establish what went wrong and whether it could have been avoided. Not all Saers find fault with the patient's care, but the objective is to improve safety. NHS Lanarkshire was only able to provide data from April 2015 onwards, but this revealed a total of 194 Saers - of which 102 related to neonatal or maternity services, and 80 for obstetrics. A Fatal Accident Inquiry involving NHS Lanarkshire has already been ordered into the deaths of three infants - Leo Lamont and Ellie McCormick in 2019, and Mirabelle Bosch in 2021 - because they had died in "circumstances giving rise to serious public concern". Read full story (paywalled) Source: The Herald, 10 December 2022
  9. Content Article
    The Organisation for Economic Co-operation and Development (OECD) is an intergovernmental organisation with 38 member countries. While healthcare quality is improving across many OECD members countries, patient safety remains a central policy concern. The OECD has worked for several years with countries to identify and promote strategies to support cross-national sharing and learning of patient safety. The OECD collaborate with the World Health Organization and other key international bodies concerned with improving patient safety globally. This brochure highlights key areas of OECD work on patient safety.
  10. News Article
    A hospital trust has apologised to a woman for failing to admit a surgeon had been responsible for a massive haemorrhage that almost killed her after a Caesarean section. For seven years, East Kent Hospitals Trust maintained the size of Louise Dempster's baby was to blame. "It was just continuous lies," the 34-year-old told BBC News. East Kent Hospitals chief executive Tracy Fletcher promised "to ensure lessons are learned". Louise Dempster gave birth in May 2015 but the surgeon's error only emerged during an inquiry into poor maternity care at East Kent Hospitals Trust which reported this year. Read full story Source: BBC News, 9 December 2022
  11. News Article
    Three “major” reviews are being launched into a struggling teaching trust in response to growing concerns over bullying and poor workplace culture. Birmingham and Solihull integrated care board has begun a series of investigations into University Hospitals Birmingham, whose chief executive announced he was standing down last month. The first review will get under way immediately and will focus on specific allegations made recently on BBC Newsnight. These include patient safety concerns, the “bullying” of clinicians and the issues raised by a review of 12 patient deaths undertaken by former consultant Dr Manos Nikolousis in 2017. It will be led by an “experienced senior independent clinician” from outside the local health system who is expected to report by the end of January. The second and third investigations will review the trust’s leadership and broader cultural issues respectively. The probes will be carried out with UHB and NHS England. Both are expected to report in the first half of 2023. Read full story (paywalled) Source: HSJ, 9 December 2022
  12. News Article
    Nanette Barragán, US representative for California’s 44th Congressional District, has announced the introduction of new legislation intended to establish a National Patient Safety Board (NPSB) as a non-punitive, collaborative, independent agency to address safety in healthcare. This landmark legislation is a critical step to improve safety for patients and healthcare providers by coordinating existing efforts within a single independent agency solely focused on addressing safety in health care through data-driven solutions. Prior to the COVID-19 pandemic, medical error was the third leading cause of death in the United States, with conservative estimates of more than 250,000 patients dying annually from preventable medical harm and costs of more than $17 billion to the U.S. healthcare system. Recent data from the Centers for Medicare and Medicaid Services and Centers for Disease Control and Prevention indicate that patient safety worsened during the pandemic. The NPSB’s solutions would focus on problems like medication errors, wrong-site surgeries, hospital-acquired infections, errors in pathology labs, and issues in transition from acute to long-term care. By leveraging interdisciplinary teams of researchers and new technology, including automated systems with AI algorithms, the NPSB’s solutions would help relieve the burden of data collection at the frontline, while also detecting precursors to harm. A coalition of leaders in health care, technology, business, academia, and other industries has united to call for the establishment of an NPSB. “We have seen many valiant efforts to reduce the problem of preventable medical error, but most of these have relied on the frontline workforce to do the work or take extraordinary precautions,” said Karen Wolk Feinstein, PhD, president and CEO of the Pittsburgh Regional Health Initiative and spokesperson for the NPSB Advocacy Coalition. “The pandemic has now made things worse as weary, frustrated, and stressed nurses, doctors, and technicians leave clinical care, resulting in a cycle where harm becomes more prevalent. Many organizations have united to advance a national home for patient safety to promote substantive solutions, including those that deploy modern technologies to make safety as autonomous as possible.” Read full story Source: Business Wire, 8 December 2022
  13. News Article
    Racism is a “profound” and “insidious” driver of health inequalities worldwide and poses a public health threat to millions of people, according to a global review. Racism, xenophobia and discrimination are “fundamental influences” on health globally but have been overlooked by health researchers, policymakers and practitioners, the series published in the Lancet suggests. Inaccurate and unfounded assumptions about genetic differences between races also continue to shape health outcomes through research, policy and practice, the review of evidence and studies found. “Racism and xenophobia exist in every modern society and have profound effects on the health of disadvantaged people,” said the lead author, Prof Delan Devakumar of University College London. “Until racism and xenophobia are universally recognised as significant drivers of determinants of health, the root causes of discrimination will remain in the shadows and continue to cause and exacerbate health inequities.” Read full story Source: The Guardian, 8 December 2022
  14. Content Article
    This article provides an overview of the National Patient Safety Board Act of 2022; legislation which has been introduced in the USA to establish an independent federal agency dedicated to preventing and reducing healthcare-related harms.
  15. Content Article
    Operating theatres are an important focus in carbon reduction: they account for as much as 25% of hospitals’ carbon emissions, despite fewer than 5% of hospital inpatients undergoing surgery. Patient Advocate and Research Involvement Lead at University Hospitals Birmingham NHS Foundation Trust Dr Lesley Booth CBE said: “Reducing the environmental impact of surgery is hugely important to improving health more broadly. We know that climate change and air pollution have wide impacts on health, many of which aren’t measurable for years to come. “I would want my operation in a hospital that cares about the environment, showing its commitment to patients and public health.” Find out what Solihul Hospital did.
  16. Content Article
    Racism, xenophobia, and discrimination exist in every modern society causing avoidable disease and premature death among groups who are often already disadvantaged. This Lancet series examines how the historic systems and structures of power and oppression, and discriminatory ideologies have shaped policy and practice today, and are root causes of racial health inequities. Furthermore, by applying a global lens and intersectional framework, overlapping forms of oppression such as age, gender, and socioeconomic status and their impact on discrimination are analysed. Interventions to address the spectrum of drivers of adverse health outcomes with a focus on the structural, societal, legal, human right, institutional and system level are reviewed. Research recommendations and key approaches for moving forward are proposed.
  17. Content Article
    Port-au-Prince, the capital of Haiti, has seen waves of clashes between armed groups. The violence has driven a stark need for emergency trauma care and surgery, and cut people off from the everyday healthcare services they need. Nurse Amadeus von der Oelsnitz explains how the Médecins Sans Frontières / Doctors Without Borders (MSF) principles of neutrality, impartiality and independence help teams provide vital healthcare in a city torn apart by insecurity.
  18. Content Article
    For the 20th year, the Agency for Healthcare Research and Quality (AHRQ) is reporting on healthcare quality and disparities. The annual National Healthcare Quality and Disparities Report is mandated by Congress to provide a comprehensive overview of the quality of healthcare received by the general U.S. population and disparities in care experienced by different racial and socioeconomic groups. The report is produced with the help of an Interagency Work Group led by AHRQ.
  19. Event
    The new NHS Patient Safety Syllabus has brought education and training to the fore to push patient safety in healthcare. Based on the syllabus this masterclass will focus on how Human Factors and Red Teams can be improve patient safety. Red Teams are defined as a team that is formed with the objective of subjecting an organisation’s plans, programmes, ideas and assumptions to rigorous analysis and challenge. It will look at the use of Red Teaming taken from the Ministry of Defence for supporting staff and teams faced with different problems and challenges in healthcare. It will look at how you can use these techniques to improve problem solving and making decisions across all levels of the organisations. Red Teaming is the independent application of a range of structured, creative and critical thinking techniques to assist healthcare staff make a better-informed decision or produce a more robust product. Finally, it will address problems and develop capability within healthcare organisations. It introduces more formal analytical techniques that can be used with more complex problems when more time is available. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  20. Event
    The new NHS Patient Safety Syllabus has brought education and training to the fore to push patient safety in healthcare. Based on the syllabus this masterclass will focus on how Induction and Mandatory training can be improved for Patient Safety. We will look at the case for change and how we can develop a culture of learning. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  21. Event
    The publication of the New Patient Safety Incident Response Framework in August 2022 has shifted the focus towards identifying and investigating patient safety incidents and events that have the greatest potential to lead to learning and improvement. This conference focuses on patient safety learning – maximising learning and improvement from patient safety insight and events. The conference will support you to identify incidents and insight that has the greatest potential for improvement and use a range of system-based approaches for learning from patient safety incidents. The conference will also update delegates on the new Learn from patient safety events (LFPSE) service and how local incident reporting will adapt to this new system. The roles and competencies of the Learning Response Lead, and the practicalities of involving and engaging with patients to deliver continuous improvement will also be discussed. Finally the conference will share examples of Safety Actions & After Action Reviews which is recommended under the new framework. This conference will enable you to: Network with colleagues who are working to improve the learning from Patient Safety Insight and Events. Update your knowledge on the New Patient Safety Incident Response Framework published in August 2022. Ensure your approach to learning is in line with PSIRF. Understand the new roles of Patient Safety Partner, Patient Safety Specialist and Learning Response Lead. Identifying and prioritise incidents that have the greatest potential for learning. Explore the requirements and value of the Learn from patient safety events (LFPSE) service. Reflect on the perspectives of a patient who has been engaged as a patient safety partner, and understand how to engaging and involving patients, families and staff can lead to improvement. Understand behaviours, decisions and actions that allow continuous learning and improvement. Develop practical approaches to better aligning the work of patient safety and quality improvement teams. Understand how to work with staff to ensure a focus on learning and continuous improvement. Develop your skills in Leading Patient Safety Improvement and techniques for ensuring a system-based approach to learning. Identify key strategies for delivering Safety Actions & After Action Reviews: Delivering, accountability and monitoring. Supports CPD professional development and acts as revalidation evidence. This course provides 5 hours training for CPD subject to peer group approval for revalidation purposes. Register We have five free places for hub members. To secure the places, simply quote HCUK00PSL.
  22. Event
    until
    Interested in sustainability and a Greener NHS? Join the Nursing and Midwifery Sustainability Network and help improve health now and for future generations. Nurses, midwives and care staff have a unique role to play in supporting the NHS’ net zero goal. They are already making tangible changes to tackle climate change while improving care. And together, we can achieve even more. That’s why NHS England is launching a Nursing and Midwifery Sustainability Network. The network will create a space and opportunity to share ideas, successes, and innovative practices and it will help us to address barriers and discuss challenges in order for our professions to make a real impact. Nurse, midwives and care staff prove every day that that they are adept at identifying issues and creating solutions – skills that are immensely valuable in reducing the NHS carbon footprint and delivering the NHS’ net zero goal. Come along to the online launch event and first network meeting to find out more about the network and how you can get involved. Open to all nurses and midwives working within the NHS in England, please sign up using your NHS email. Further information
  23. News Article
    As the pressures of winter and the Covid treatment backlog grow, the NHS is struggling. In Manchester, one organisation is pioneering a new way to care for people that tries to reduce the burden on the health service. It's the first call-out of the day for nurse Manju and pharmacist Kara in north Manchester. They are on their way to see Steven, who has been diagnosed with Parkinson's disease and had a fall the previous night. This might have led to a call-out for an ambulance crew and a visit to A&E. But instead the Manchester Local Care Organisation (LCO) stepped in. Once at Steven's house, Manju makes sure he hasn't been harmed by his fall, while Kara checks his medication. Manju notes that Steven's tablets could have contributed to his fall. Manju asks Steven how he copes going up and down the stairs. "I'm OK, just about," he says. But when he has a go at coming down the stairs, Manju spots he could use an extra grab rail and says she will sort one out. This intervention by the team has not only avoided Steven ending up in A&E, but also ensures he can continue to live independently in his own home. That's a key part of the LCO mission, according to Lana McEwan, one of the team leaders in north Manchester. "We would consider ourselves to be an admission-avoidance service, so we're trying to prevent ambulances being called in the first instance. "When an ambulance has been called, we're taking referrals directly from the ambulance service and responding within a one or two-hour response depending on need, and that's an alternative to A&E." Local neighbourhood teams are made up of nurses, social workers, pharmacists and doctors, all working together to keep people out of hospital. Read full story Source: BBC News, 9 December 2022
  24. News Article
    The number of people waiting more than two months to start cancer treatment remained over 30,000 — double the pre-covid level — for three months to the end of October, according to new data published. NHS England previously committed to bringing the number of people waiting longer than 62 days to be diagnosed and begin treatment, after referral for suspected cancer, to pre-pandemic levels – roughly 14,000 – by March 2023. But the number has been generally growing since the spring, and remained above 30,000 from August through to the end of October, the latest figures available. September and October’s monthly totals were higher than the previous monthly peak in May 2020, after services were disrupted in the first covid wave. The increase in waiters this year has been caused by diagnostic and treatment capacity falling short of an increased number of referrals. Matt Sample, policy development manager at Cancer Research UK, said: “While it’s good to see significant numbers of people coming forward with potential cancer symptoms, performance against key targets are among the worst on record, continuing a trend that existed long before the pandemic hit, with one target having been missed for almost seven years.” Read full story (paywalled) Source: HSJ, 8 December 2022
  25. News Article
    Busy, noisy, highly stressful - and sometimes violent. This is the reality of A&E as the NHS gears up for what will be an incredibly difficult winter. That much is clear from the experience of staff and patients at Royal Berkshire Hospital's emergency department. Like all units, it is struggling to see patients quickly - more than a third of patients wait more than four hours. The stress and frustration means tempers can easily boil over. Receptionist Tahj Chrichlow says it can get so busy patients end up "packed like sardines". "Sometimes people can be not as nice to us as we like," he adds, explaining how earlier this week the window of the reception office had been smashed by one angry person. The Royal College of Emergency Medicine is warning delays are putting patients at risk. Vice president Dr Ian Higginson says hospitals are "full to bursting". "When our hospitals are full, we can't get patients out of our emergency departments. "That means emergency departments become overcrowded and we see patients waiting for long periods on uncomfortable trollies in corridors or other rubbish places." Dr Higginson says his colleagues are "very worried" and unable to deliver the care they would like to give to patients. Read full story Source: BBC News, 8 December 2022
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