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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Mary Dixon Woods discusses the problem of context in quality improvement in this Health Foundation paper.
  2. Content Article
    Video recording and slides of a webinar presented by Mary Dixon-Woods, Professor of Medical Sociology and Wellcome Trust Investigator.
  3. News Article
    The Government has insisted that plans to build 48 ‘new’ hospitals by 2030 will still go ahead, despite widespread concerns over timelines and increasing construction costs. In its 2019 manifesto, the Conservative Party announced the New Hospitals Programme, a pledge to build 48 new hospitals across the country, including eight schemes that had been announced by previous governments. However, since then, the number has been seemingly interchangeable, with the Government, in a response to questions from BBH, referring to just 40 developments in total, even though the GM Government website clearly mentions 48. And, to date, just two of those projects have been completed, while only five others are under construction. The remaining schemes are still in the planning or approval stages, and this, combined with rising inflation and construction costs and a shortage of building materials, has led to concerns that they will not go ahead. Read full story Source: Building Better Healthcare, 28 November 2022
  4. Content Article
    This analysis from the Health Foundation examines how healthcare spending in the UK compares with EU countries in the decade preceding the pandemic. Taking a longer-term view enables us to see how trends in spending may have impacted healthcare resilience today.
  5. Content Article
    Patient (or lived experience) leadership involves those affected by life-changing illness, injury or disability becoming equal partners in NHS decision-making. Patient leadership champion David Gilbert picks out the most significant developments in a field of increasing relevance to the NHS.
  6. Content Article
    In this episode of 'Better Never Stops', Virginia Mason Institute Senior Partner Melissa Lin interviews Dana Nelson-Peterson, Vice President of Nursing Operations at Virginia Mason Franciscan Health, who shares what happens when you trust a management system and improvement process to solve your toughest challenges. Dana shares her story of leading a critical part of Virginia Mason’s Covid response.
  7. Content Article
    The Psychological Professions Network is a membership network commissioned by Health Education England for all psychological professionals and other stakeholders in NHS commissioned psychological healthcare, whether you work with children, adults or another population, whether you are in training or qualified, a manager, commissioner, educator, or an expert by experience.
  8. News Article
    GPs are leaving UK practice over workplace incidents rather than due to falling ‘out of love’ with the profession, the General Medical Council (GMC) has warned. Speaking to the NHS Providers conference (16 November), chief executive Charlie Massey said that many specialty and associate specialist (SAS) and locally employed (LE) doctors feel their careers are being ‘curtailed’ and that they ‘can’t tolerate the environments’ in which they work. He cited new GMC research into doctors’ migration which identified poor workplace conditions and ‘negative experiences with colleagues’ as a ‘far more impactful’ as a trigger compared to poor experiences with patients. According to the research, bullying at work, lack of respect from line managers and experiences of favouritism ‘provided the nudge for them to consider making a change and migrating abroad’. Mr Massey said: "This is a senseless waste of talent, not least because these issues are preventable. With a focus on compassionate, supportive cultures, they can be put right. This will not only improve doctors’ wellbeing, but also their productivity. Happier workers are better workers, and they deliver better results." Read full story Source: Healthcare Leader, 16 November 2022
  9. News Article
    Greg Price died of complications after testicular cancer surgery, but a review of his case found missed faxes, follow-ups and botched data-sharing ultimately cost the vibrant 31-year-old Alberta man his life. All the missteps in his case meant it took 407 days from his first complaint for Price — an engineer, pilot, and athlete — to be diagnosed with cancer. He died three months after his doctor said he should see a specialist, and while he was being passed between multiple doctors, his health data often was not. Now, his sister, Teri Price, says too little has changed in medical information-sharing in the decade since her brother's death. This, despite a review of his case — the 2013 Alberta Continuity of Patient Care Study — that recommended life-saving changes to the healthcare system to avoid more experiences like his. So, she's fighting to improve the system that she says not only failed her brother, but keeps failing to change. Price says that Canadians assume that their health information is shared between doctors to keep them safe and studied to improve the system, but often, it's not. And medical front-line staff in Canada say problems persist when it comes to sharing everything from patient information to aggregate medical and staffing data. "Information tends to be broken up between the services that patients attend," said Ewan Affleck, a doctor in the Northwest Territories who has spent his career fighting for better data access, and a member of the expert advisory arm of the Pan-Canadian Health Data Strategy Group. "The cohesion and use of health data in Canada is legislated to fail." Read full story Source: CBC News, 17 November 2022
  10. News Article
    Health and Human Services (HHS) Secretary Xavier Becerra startled a recent meeting of senior health system leaders by declaring in opening remarks that a plane crash had just killed all 200 passengers. He immediately added that this hadn’t really happened; he’d said it only to illustrate the toll taken by medical error. The 14 November meeting at which Becerra spoke signalled a renewed commitment by HHS to preventing patient harm as it launched an “Action Alliance to Advance Patient Safety.” The Alliance aims to recruit the nation’s largest health systems as participants. “We’re losing pretty much an airline full of Americans every day to medical error, but we don’t think about it,” said Becerra. (The department’s fiscal 2022-2026 strategic plan actually estimated the death toll at roughly 550 daily, which would be a very large airliner.) “But the worst part about it is that it’s avoidable.” Though the meeting rhetoric was rousing and the invitee list impressive, specifics remained scarce. The Alliance is described only in general terms as a partnership among health systems, federal agencies, patients and others to implement Safer Together: A National Action Plan to Advance Patient Safety. Read full story Source: Forbes, 17 November 2022
  11. Content Article
    Behind the scenes at one of the UK’s biggest hospitals as it transitions from old to new.  The Royal Liverpool University Hospital moves thousands of patients and staff to a new building. This programme documents their journey, the challenges faced and human factors involved.
  12. Content Article
    On 1 November 2022, Dr Bill Kirkup, HSIB's Clinical Director of Maternity Investigations, and lead investigator for the investigation into maternity and neonatal services at East Kent Hospitals University NHS Foundation Trust, presented the investigation report: 'Reading the signals' in a seminar delivered to HSIB staff.
  13. News Article
    The Government is looking to hire a new cyber security chief for the NHS and Department of Health and Social Care (DHSC), at a time of heightened risk of cyber attacks against the health service. The DHSC last month issued a job advert for a “national chief information security officer”, who will sit within the digital policy unit of NHS England’s transformation directorate. It comes at a time when the risk of cyber attacks against the NHS is increasing. Earlier this summer, an attack on an NHS electronic patient record supplier impacted several providers, including a dozen mental health trusts, with some trusts still not having recovered their service fully. Meanwhile, in February, NHSE wrote to trusts to tell them to strengthen their cyber defences in the wake of Russia’s invasion of Ukraine. Read full story (paywalled) Source: HSJ, 18 November 2022
  14. News Article
    More than two million people in the UK say they have symptoms of Long Covid, according to the latest Office for National Statistics (ONS) survey. Many long Covid patients now report Omicron was their first infection. But almost three years into the pandemic there is still a struggle to be seen by specialist clinics, which are hampered by a lack of resources and research. So has the condition changed at all, and have treatments started to progress? NICE defines Llong Covid, or post-Covid syndrome, as symptoms during or after infection that continue for more than 12 weeks and are not explained by an alternative diagnosis. An estimated 1.2m of those who answered the ONS survey reported at least one such symptom continuing for more than 12 weeks - health issues that they didn't think could be explained by anything else. It's easy to assume that new cases of long Covid have significantly decreased, given recent research suggesting the risk of developing long Covid from the Omicron variant is lower. However, the sheer scale of cases over the past year has resulted in more than a third of people with long Covid acquiring it during the Omicron wave, according to the ONS. Patients are usually referred to post-Covid assessment clinics after experiencing symptoms for 12 weeks - however, waiting times have not improved much within the past year. The latest NHS England figures show 33% of Londoners given an initial assessment had to wait 15 weeks or more from the time of their referral, compared to 39% from a similar period in 2021. The British Medical Association (BMA) has called on the government to increase funding for Long Covid clinics to deal with ever-increasing patient numbers. The BMA says that NHS England's 2022 strategy set out in July failed to announce any new funding. Read full story Source: BBC News, 18 November 2022
  15. Content Article
    The UK continues to feel the consequences of the Covid-19 pandemic, both through its impact on the nation’s health, as well as the prolonged impact on the UK economy. Yet despite this, there isn’t enough attention on boosting population health, the NHS and social care to build resilience to future shocks and support economic recovery. For the 2022 REAL challenge lecture, Andy Haldane, Chief Executive of the RSA and former Chief Economist at the Bank of England, explored the relationship between health and wealth. He drew lessons from the pandemic and argued for a more holistic economic growth strategy where health and wealth are inextricably linked.
  16. Content Article
    The Covid-19 pandemic has led to the reorganisation of healthcare services to limit the transmission of the virus and deal with the sequelae of infection. This reorganisation had a detrimental effect on cardiovascular services, with reductions in hospitalisations for acute cardiovascular events and the deferral of all but the most urgent interventional procedures and operations. Aortic stenosis (AS) is the most common form of valvular heart disease. Once stenosis is severe, symptoms follow and the prognosis is poor, with 50% mortality within 2 years of symptom onset. Thus, timely treatment is of paramount importance. There was a large decline procedural activity to treat severe AS during the COVID-19 pandemic.  As we move into an era of ‘living with’ COVID-19, plans must urgently be put in place to best manage the additional waiting list burden for treatment of severe AS. In this study, Stickels et al. used mathematical methods to examine the extent to which additional capacity to provide treatment of severe AS should be created to clear the backlog and minimise deaths of people on the waiting list.
  17. News Article
    Ambulance waiting times for stroke and suspected heart attacks have quadrupled in four parts of England since before Covid-19 – whereas others have only grown by half – underlining the severe impact of long accident and emergency handovers. Response times have leapt across England over the past two years, particularly for category 2 and 3 incidents, but the data makes clear that the steepest increases are in areas where hospitals have the biggest handover delay problems. Of the 10 patches with the largest increases in average category 2 performance between 2018-19 and 2021-22, four are served by major hospitals which make up NHS England’s “cohort one” of trusts selected for the worst handover problems; and four more are on government’s list of 15 which accounted for the most long handover delays last winter. The increase in handover delays – in turn linked to delayed discharge, staffing, lack of community services and social care’s collapse – are the stand-out reason for areas with a steep rise in response times. Read full story (paywalled) Source: HSJ, 18 November 2022
  18. News Article
    Children say they were “treated like animals” and left traumatised as part of a decade of “systemic abuse” by a group of mental health hospitals, an investigation by The Independent and Sky News has found. The Department of Health and Social Care has now launched a probe into the allegations of 22 young women who were patients in units run by The Huntercombe Group, which has run at least six children’s mental health hospitals, between 2012 and this year. They say they suffered treatment including the use of “painful” restraints and being held down for hours by male nurses, being stopped from going outside for months and living in wards with blood-stained walls. They also allege they were given so much medication they had become “zombies” and were force-fed. Through witness testimony, documents obtained by Freedom of Information request and leaked reports, the investigation has uncovered: The CQC has received more than 700 whistleblowing and safeguarding reports, including “incidents of concern” and several “sexual safety” concerns. NHS England was notified of 195 safeguarding reports between 2020 and 2021. A 2018 internal report at Meadow Lodge hospital in Newton Abbot (now closed) found staff members using sexually inappropriate language in front of patients. 160 reports investigated by Staffordshire police about Huntercombe Staffordshire between 2015 and 2022. Between March 2021 and 2022, the CQC gave permission for 29 patients to be admitted to Maidenhead hospital after it was placed in special measures. Read full story Source: The Independent, 17 November 2022
  19. News Article
    The NHS will receive an extra £3.3bn in each of the next two years, the chancellor has announced, but experts warn the cash is probably only half of what is needed to keep the health service afloat. Jeremy Hunt told the Commons during his autumn statement he had been assured the funding would mean the NHS can hit its “key priorities”. Its chief executive, Amanda Pritchard, later issued a statement welcoming the funding, saying it showed that “the government has been serious about its commitment to prioritise the NHS”. However, it was only last month that NHS England, the organisation Pritchard leads, had forecast a £7bn shortfall in its funding next year, which it warned it could not plug with efficiency measures alone. “The NHS warned it needed more money to cope with the impact of inflation on its costs,” said Nigel Edwards, the chief executive of the independent thinktank Nuffield Trust. “Today’s autumn statement has provided much-needed extra cash from April over the next two years, but this is only around half of what the NHS had warned last month would likely be needed.” Hunt pledged to grow the NHS budget in 2023-24 and 2024-25 by £3.3bn in each year. But Edwards warned that would not account for the £2.5bn worth of inflation and other unexpected cost pressures the NHS has faced in the current financial year. “The impact of today’s funding announcement is that real terms health spending per head after adjusting for age will increase by less than 1% for the next two years,” Edwards added. “This is compared to the long-term average of 2.6% and comes at a time when the NHS cannot afford to stand still and is desperately trying to increase the work it can do to clear record waiting times.” Read full story Source: The Guardian, 17 November 2022
  20. News Article
    A US Senate investigation into allegations that unwanted medical procedures were performed on detained female immigrants in Georgia has uncovered “a catastrophic failure by the federal government” to protect the detainees. A Senate hearing on Tuesday by the bipartisan permanent subcommittee on investigations (PSI), chaired by the Georgia senator Jon Ossoff, announced its findings on conditions and practices at the Irwin county detention center (ICDC). The ICDC, located in Ocilla, Georgia, housed detainees who shared accounts of poor treatment including gynaecological procedures that were “excessive, invasive and often unnecessary”. An account of what was occurring at the ICDC first came to light when Dawn Wooten, a nurse at the facility, acted as a whistleblower. Ossoff called the alleged unnecessary and sometimes non-consensual medical treatment and procedures disclosed in the 18-month investigation “nightmarish and disgraceful”. Ossoff said: “This is an extraordinarily disturbing finding, and in my view represents a catastrophic failure by the federal government to respect basic human rights.” The report detailed the harrowing account of an unnamed woman who was detained in the ICDC in 2020. The detainee describes how Dr Mahendra Amin allegedly removed a portion of her fallopian tube, a result of a dilation and curettage procedure she was not made aware of, and how Amin told her “she would never be able to have children naturally again”. Read full story Source: The Guardian, 15 November 2022
  21. Content Article
    Geraint Jones, a healthcare worker at a hospital in Wales, shares his experiences of Long Covid. Geraint tested positive for COVID-19 in April 2020, whilst working on the COVID-positive wards in a district general hospital.  This long-lasting illness is still little understood, but new research is uncovering some of the recurring symptoms that many patients experience and suggesting better options for treatment for adults and children.
  22. Content Article
    Most healthcare systems across the globe are dealing with the reality of limited resources and staffing shortages. Therefore, it is more important than ever to ensure that health care professionals spend time on doing what matters most and providing the most value for service users. Meaningful time spent face to face is a high priority for both service users and health care professionals. Paying more attention to computers than people because of the demands of burdensome documentation diverts our attention from direct care. It is a situation that is unsatisfactory for all parties. The Danish municipality of Sønderborg, a safety leader in nursing home and home-based care for more than a decade, decided to see what could be done. With improvement science already embedded in their organisation, they decided to take a deep dive into their processes as a first step. Mistakes in documentation, coordination, and communication have been identified as among the top 10 of root causes of patient safety incidents in Denmark, so it made sense to start there. Patient safety is often cited as the reason for documentation, but some research indicates that burdensome documentation is associated with increased medical errors, mistakes in documentation, and burnout among health care providers. Working from the theory that safely simplifying or streamlining documentation would free up time for direct care, Sønderborg and the Danish Society for Patient Safety embarked on an improvement journey that started with understanding the workflow of documentation that enabled staff to seek and share information from one another to plan and perform different tasks.
  23. Content Article
    This tool was developed collaboratively between the Association for Perioperative Practice (AfPP), NHS England (NHSE) and BD to guide perioperative staff in selecting the most appropriate skin preparation solution for respective surgical procedures. By providing a combination of cues pre-defined and selected by the user, this tool recommends the most appropriate surgical skin antiseptic solution, method of use, technique, and precautions. The development of this clinical interactive decision-making tool provides healthcare professionals with evidence-based information at their fingertips to manage surgical site skin preparation effectively. This facilitates clinical decisions in practice, saving time and reducing harm.
  24. Content Article
    This BMJ Practice Pointer discusses how we can support our colleagues with their mental health.
  25. Content Article
    After a prolonged battle with the COVID-19 pandemic, healthcare providers now face the next crisis that has been brewing even longer: staff shortages and an increasingly exhausted workforce. In early 2022, almost one in two (47%) healthcare professionals reported feeling burned out, up from 42% last year. Many consider leaving the field, adding to the worries of employers who see growing demand for care without enough hands at the bedside to cater for their patients. Can AI be part of the solution by helping healthcare professionals reclaim the joy in their work? An article by Philips.  
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