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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Same-day access hubs will not be mandated in North West London as the Integrated Care Board (ICB) bows to pressure from GPs and patients. In a letter to GP teams, seen by Pulse, the ICB said that their controversial same-day access programme "will not form part of the single offer for enhanced services for 2024/25". Instead, ICB leaders said they want to work with PCNs "to consider how access can be improved" and that they do not have a "presumption" about a "particular model" all PCNs should adopt. They are now aiming for a new model to be implemented from April next year instead. The hub model aimed to "deliver a single point of triage for same-day, low complexity" demand for all 2.1 million residents within the integrated care system, leaving GP practices with only longer-term, "complex" care. But London GP leaders, as well as patients, raised "immense concern" with the plans, including patient safety, quality of care, and logistics. In response to these concerns, the ICB confirmed yesterday that it has "adjusted" the same-day hub programme, and that it wants to "move forward collectively" to address both patient access issues and GP pressures. Read full story Source: Pulse, 6 March 2024
  2. Event
    Join us for a full day of education covering those topics that are the basis of our (or your) everyday practice. From risk management to infection control and patient care to practitioners wellbeing, leave the day informed, challenged and inspired. Book your tickets
  3. Content Article
    Martha's rule stipulates the right of patients and their families to escalate care as a way to improve safety while in hospital. This article analyses the possible impact of the proposed policy through the lens of a behaviour change framework and explores new opportunities presented by the implementation of Martha's rule.
  4. News Article
    The menopause is not a disease and is being “over-medicalised”, experts have said. High-income countries, including the UK, commonly see menopause as a medical problem or hormone-deficiency disorder with long-term health risks “that are best managed by hormone replacement (therapy)”, they said. Yet, around the world, “most women navigate menopause without the need for medical treatments”, the experts, including from the Royal Women’s Hospital in Melbourne, Australia, and King’s College London, said. They argued there is a lack of data on whether health problems are caused by menopause or simply by ageing. In a first paper in The Lancet Series on the menopause, the experts said: “Although management of symptoms is important, a medicalised view of menopause can be disempowering for women, leading to over-treatment and overlooking potential positive effects, such as better mental health with age and freedom from menstruation, menstrual disorders, and contraception.” Series co-author Professor Martha Hickey, from the University of Melbourne and Royal Women’s Hospital, said: “The misconception of menopause as always being a medical issue which consistently heralds a decline in physical and mental health should be challenged across the whole of society. “Many women live rewarding lives during and after menopause, contributing to work, family life and the wider society. “Changing the narrative to view menopause as part of healthy ageing may better empower women to navigate this life stage and reduce fear and trepidation amongst those who have yet to experience it.” Read full story Source: The Independent, 5 March 2024
  5. Content Article
    Menopause is an inevitable life stage for half the the world’s population, but experiences vary hugely. Some women have few or no symptoms over the menopause transition while others have severe symptoms that impair their quality of life and may be persistent. Many women feel unsupported as they transition menopause. To better prepare and support women, the Lancet Series on menopause argues for an approach that goes beyond specific treatments to empower women with high-quality information, tools to support decision making, empathic clinical care, and workplace adjustments as needed. Targeted support is needed for groups who experience early menopause or treatment-induced menopause, and for those at increased risk of mental health problems. The authors recognise how gendered ageism may contribute to negative experiences of menopause and call for reduced stigma and greater recognition of the value and contribution of older women. Further reading on the hub: The impact of menopause on mental health (HSSIB blog All-Party Parliamentary Group on Menopause: Inquiry to assess the impacts of menopause and the case for policy reform - conclusions Raising awareness of surgical menopause
  6. News Article
    A patient says he felt ignored and that NHS care was lacking after he spent 14 hours on a bed in a hospital corridor. Ivan Philpotts, 77, from Norwich, was transferred between wards at the Norfolk & Norwich University Hospital (NNUH), having contracted pneumonia. He said he was left in a bed in a corridor with no access to water, was unable to eat and that his wife was unable to visit. The hospital said it had experienced a high number of patients last week. "I felt very vulnerable," Mr Philpotts said. "Nobody seemed to be taking any notice of you and you were sitting there, people walking by you. "I was there from 8.30 in the morning until 9.10 at night before I actually got into a bay. We got no communication whatsoever." The hospital trust is one of just two in England that has been carrying out a trial of a "corridor care" scheme. The Royal College of Nursing's eastern regional director Teresa Budrey said: "We're starting to normalise it and that's not OK. "There are patients who are suffering for hours, without proper privacy or equipment and you've also got nurses dealing with an expanded number of patients. "We need government minsters and employers to come together for some bigger solutions across the system." Read full story Source: BBC News, 6 March 2024 Further reading on the hub: A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift
  7. Content Article
    One of the major challenges of patient safety incident reporting and learning systems lies in the difficulties of extracting practical information from the vast amount of data collected. Furthermore, many countries have not started collecting incident reports in patient safety at national level which makes it difficult to identify avoidable patient safety incidents and take action on them nationally. Minimal Information Model for Patient Safety (MIM PS) has been developed to provide a simple tool to start collecting data on patient safety incidents to assist in data analysis and extract the minimal, but necessary information to learn from incidents in order to avoid recurrence of same types of incidents in the future. Also, the MIM PS can be used as mapping source from any types of existing reporting systems of patient safety incidents which means no need to develop the new reporting systems based on MIM PS. This MIM user guide aims to explain each MIM category and how to implement MIM. It went through a validation process with EU and EFTA countries in 2014-2015. The MIM PS validation was supported by European Union in which EFTA countries also participated in the pilot testing.
  8. News Article
    Patient safety has been put at risk by ministers striking a backroom deal with unions to cut the equivalent of 10,000 health service jobs by reducing the working week, NHS bosses have warned. Briefings prepared by the chief executives of Scotland’s NHS boards reveal top management thrown into chaos after appearing to be blindsided by the new health secretary, Neil Gray. Two weeks into the role, Gray, who replaced the scandal-hit Michael Matheson on 8 February met with unions without NHS staff present and signed off sweeping changes to working conditions, setting a deadline to implement them within five weeks. The Scottish Conservatives have called the deal “deeply alarming”, while Labour accused the new health secretary of “standing idly by while chaos looms”. Read full story (paywalled) Source: The Times, 4 March 2024
  9. News Article
    Shortly before Joseph Ladapo was sworn in as Florida’s surgeon general in 2022, the New Yorker ran a short column welcoming the vaccine-skeptic doctor to his new role, and highlighting his advocacy for the use of leeches in public health. It was satire of course, a teasing of the Harvard-educated physician for his unorthodox medical views, which include a steadfast belief that life-saving Covid shots are the work of the devil, and that opening a window is the preferred treatment for the inhalation of toxic fumes from gas stoves. But now, with an entirely preventable outbreak of measles spreading across Florida, medical experts are questioning if quackery really has become official health policy in the nation’s third most-populous state. As the highly contagious disease raged in a Broward county elementary school, Ladapo, a politically appointed acolyte of Florida’s far-right governor Ron DeSantis, wrote to parents telling them it was perfectly fine for parents to continue to send in their unvaccinated children. “The surgeon general is Ron DeSantis’s lapdog, and says whatever DeSantis wants him to say,” said Dr Robert Speth, a professor of pharmaceutical sciences at south Florida’s Nova Southeastern University with more than four decades of research experience. “His statements are more political than medical and that’s a horrible disservice to the citizens of Florida. He’s somebody whose job is to protect public health, and he’s doing the exact opposite.” Read full story (paywalled) Source: Guardian, 3 March 2024
  10. News Article
    MPs are calling for a new review into the dangers of the drug Primodos, claiming that families who suffered avoidable harm from it have been "sidelined and stonewalled". MPs said the suggestion there is no proven link between the hormone pregnancy test and babies being born with malformations is "factually and morally wrong". A report by the All-Party Parliamentary Group (APPG) on hormone pregnancy tests claims evidence was "covered up" and it is possible to "piece together a case that could reveal one of the biggest medical frauds of the 20th century". Around 1.5 million women in Britain were given hormone pregnancy tests between the 1950s and 1970s. They were instructed to take the drug by their GPs as a way of finding out if they were pregnant. But Primodos was withdrawn from the market in the UK in the late 1970s after regulators warned "an association was confirmed" between the drug and birth defects. However, in 2017 an expert working group found there was insufficient evidence of a causal association. But MPs now claim this report is flawed. It's hugely significant because the study was relied upon by the government and manufacturers last year to strike out a claim for compensation by the alleged victims. Read full story Source: Sky News, 1 March 2024
  11. News Article
    Opill, the first birth control pill approved for over-the-counter distribution, is now being shipped to retailers and pharmacies, the company behind the pill, Perrigo, announced on Monday. It will be available in stores and online later this month. The Food and Drug Administration approved Opill last year, paving the way for the United States to join the dozens of countries that have already made over-the-counter birth control pills available. Opill, which works by using the hormone progestin to prevent pregnancy, is meant to be taken every day around the same time and, when used as directed, is 98% effective. The pill’s arrival on shelves comes at a deeply fraught time for US reproductive rights: not only has the US supreme court demolished the national right to abortion, but the nation’s highest court is set to hear arguments over two abortion-related cases over the next few months. “Week after week, we hear stories of people being denied the reproductive health care they so desperately need because of politicians and judges overstepping into the lives of patients and providers. Today, we get to celebrate different news,” Dr Tracey Wilkinson, a pediatrician in Indiana and a board member with Physicians for Reproductive Health, said in a statement. “As Opill makes its way to pharmacies across the country, I am relieved to know that birth control access will become less challenging for so many people, but especially young people.” Read full story Source: The Guardian, 4 March 2024
  12. Event
    In the dynamic landscape of healthcare, the unexpected deterioration of a hospital patient can present daunting challenges for both medical professionals and families alike. It is during these critical moments that the significance of patient rescue becomes abundantly clear. From the perspective of physicians, nurses, and other healthcare providers, swift and effective intervention is imperative to ensure the best possible outcome. However, the role of the patient's family in such situations is equally crucial. Empowered with knowledge and equipped with effective communication strategies, families can play a pivotal role in advocating for their loved ones and contributing to the overall success of rescue efforts. The World Patients Alliance is pleased to organise a webinar titled “The Deteriorating Patient: When a hospital patient unexpectedly goes downhill, what can families do?" Join the webinar and delve into the importance of patient rescue from the physician's perspective, explore real-life patient stories, introduce Martha's Rule as a guiding principle, analyse the current state of rapid response protocols, and discuss the critical role of families in effectively communicating concerns. Register
  13. Content Article
    Elective care refers to when patients receive non-urgent treatment, normally in hospital, including, tests and scans, outpatient care, surgery and cancer treatment. The NHS is currently seeing long waiting times for some elective procedures, with the Government setting an ambition to reduce elective waiting times to less than a year by 2025. Increased waiting times mean patients have to wait longer for the care they need. This can lead to patients suffering increased pain, their condition may worsen, or they may develop other illnesses associated with the reason that they are waiting for elective care. This can cause both physical harm and mental distress to patients, their families, and carers. The Health Services Safety Investigations Body (HSSIB) Senior Safety Investigator, Neil Alexander, blogs about the challenges facing the NHS in tackling the elective care backlog and how learning from our investigation reports may be able to help the NHS rise to this challenge.
  14. Content Article
    The third action plan setting out how the Department of Health and Social Care and delivery partners will implement the UK Rare Diseases Framework in England.
  15. News Article
    Medical leaders support a planned increase in the number of physician associates (PA) in the NHS. But the British Medical Association (BMA) is concerned about a new law allowing the General Medical Council (GMC) to regulate PAs, who must be supervised by a fully qualified doctor. The doctors' union says it blurs the lines between doctors and PAs and could risk patient safety. Two families whose relatives were seen by PAs want the roles defined. The NHS has 3,286 PAs, who assist healthcare teams and are not authorised to prescribe or request scans. PAs and anaesthetic associates (AA) qualify after a funded two-year master's degree. They often have a science undergraduate degree, but that is not a prerequisite. Their role includes taking medical histories, conducting physical examinations and developing treatment plans. Like PAs, AAs are healthcare professionals who work as part of a multidisciplinary team with supervision from a named senior doctor. The Academy of Medical Royal Colleges said on Tuesday that it welcomes a push to increase the number of PAs in the NHS, but that it is "vital" that there are clear guidelines on how they are deployed. Read full story Source: BBC News, 5 March 2024
  16. News Article
    Medics and managers must overcome a system-wide “aversion” to risk after their integrated care system was identified as a national outlier for low numbers of patients discharged home, according to the ICS’s chief executive. Kate Shields, CEO of Cornwall and Isles of Scilly ICS, has highlighted a discrepancy between the ICS and the rest of England, with a lower proportion of patients discharged with no new social care requirements, or discharged directly to their own home, with only intermediate additional care (known as ”pathways” 0 and 1 in national discharge guidance). Problems with delayed patient discharges – known as “no criteria to reside” patients – are a major contributor to overcrowding and long waits in the emergency department at Royal Cornwall Hospitals Trust, as well as severe delays for ambulances to handover patients. Discharge on pathways 2 and 3 – to a care home or intermediate care bed, with substantial additional care requirements – typically take a lot longer, and require more resources. Ms Shields’ comments come 18 months after an external report warned of an “over-reliance on bedded care” in Cornwall. Speaking at a meeting of Cornwall and Isles of Scilly Integrated Care Board last month, Ms Shields said the health economy needed to “look at how we get people out of hospital faster”. Read full story (paywalled) Source: HSJ, 4 March 2024
  17. News Article
    A surgeon sacked by a hospital after raising safety concerns has accused the trust of a cover-up after a patient was partially blinded during an operation. Juanita Graham, 41, lost the sight in her left eye during an operation at Bath's Royal United Hospital (RUH) in 2019. She is now suing the trust. Serryth Colbert said he was put down as the lead author on an investigation into the incident, but said he "did not write a word" of it. Mr Colbert has described the hospital investigation into Mrs Graham's operation as "deeply flawed". The surgeon, who specialises in the head, neck, face and jaw, has made several serious allegations about patient safety at the RUH, and believes these claims led to him being regarded as a troublemaker and dismissed in October 2023. Mrs Graham, from Trowbridge, said she was still traumatised by the operation on her eye. "I remember coming round, seeing the time and felt like a gush and I couldn't see," she said. "The next time I remember waking up again, I thought it was my partner but it was a surgeon and he was crying. I said 'what's gone wrong?'". After the operation, a Root Cause Analyses (RCA) report produced by the trust said the hospital was not to blame, although it did say the risks could have been explained more clearly to Mrs Graham. Mr Colbert, whose name was added as the lead investigator, said his only involvement in the report was when he was called on the phone by a nurse, who he said did the RCA, to explain what the operation involved. The 48-year-old surgeon said: "I have been put down here to my amazement as the lead author on this. "That is not correct. I did not write a word of this. "The conclusion is the root cause of the complication was down to a bit of paperwork which could have been performed a bit better. "The root cause was not down to paperwork. It was all covered up... that was indefensible." Read full story Source: BBC News, 29 February 2024
  18. Content Article
    Hospital staff members experience 1.17 aggressive events — verbal and/or physical — for every 40 hours worked, with more aggression events occurring when staff have significantly greater numbers of patients assigned to them this study from DeSanto Iennaco et al. found. The study, published in The Joint Commission Journal on Quality and Patient Safety, examined incidence of patient and visitor aggressive events toward staff at five inpatient medical units in community hospitals and academic hospitals in the Northeastern U.S. The data was collected using even counters, aggressive incident and management logs and demographic forms over a 14-day period in early 2017.
  19. Content Article
    The Falls and Fragility Fractures Audit Programme (FFFAP) is looking to recruit new members to their award-winning Patient and Carer Panel. FFFAP is a national clinical audit run by the Royal College of Physicians (RCP) and commissioned by the Healthcare Quality Improvement Partnership on behalf of NHS England and the Welsh Government. Their work aims to improve the care that patients with fragility fractures receive in hospital and after discharge and to reduce inpatient falls. 
  20. Content Article
    As the USA's largest health insurer, the Centers for Medicare & Medicaid Services (CMS) has established quality standards, metrics, and programmes to improve healthcare not just for the 170 million individuals supported by its programmes, but for all Americans. The 2024 National Impact Assessment of CMS Quality Measures Report (Impact Assessment Report) assesses the quality and efficiency impact of measures endorsed by the consensus-based entity and used by CMS.
  21. News Article
    A new CMS report reveals disparities in care quality and patient safety within US hospitals before and during the pandemic, finding "a large proportion of measures had worse than expected performance." CMS released its 2024 National Impact Assessment Feb. 28, which is released every three years and evaluates the measures used in 26 CMS quality and value-based incentive payment programs. This edition of the report compares quality measure scores pre-COVID-19 with hospitals' results in 2020 and 2021, the initial years of the COVID-19 public health emergency. Here are eight findings from the 72-page assessment: 1. During 2020 and 2021, a large proportion of measures had worse than expected performance, including significant worsening of key patient safety metrics. 2. Half or more of the performance measures in five priorities had worse results in 2021 than expected from the 2016–2019 baseline. Priorities with the highest proportions of worse-than-expected results in 2021 were wellness and prevention (69%), behavioural health (55%), safety (54%), chronic conditions (52%), and seamless care coordination (50%). 3. Specific to safety, standardised infection ratios worsened significantly in hospitals for central line–associated bloodstream infections (94% worse), MRSA (55% worse) and CAUTI (34% worse). Before the Covid-19 PHE (2015–2019), 34,455 fewer healthcare-associated infections (HAIs) were reported in acute care settings. 4. More than 35% of measures in two priorities had better results in 2021 than expected from 2016–2019 baseline trends. Those priorities are seamless care coordination (50%) and affordability and efficiency (38%). 5. Specific to affordability and efficiency, emergency department visits for home health patients fared 1.4 percentage points better, and acute care hospitalization in the first 60 days of home health in 2021 was 1.5 percentage points better. 6. Accountable entities with the highest proportions of worse than expected results in 2021 were clinicians (64%), accountable care organizations (54%), and acute care facilities (54%). 7. Wellness and prevention had the highest percentage of measures showing health equity disparities; notable examples include pneumococcal and influenza vaccinations among racial and ethnic groups. 8. Comparison racial and ethnic groups fared worse than the White reference group on 40 of 45 (88.9%) affordability and efficiency measures and 32 of 41 (78%) chronic conditions measures. For example, disparities were recorded for Black or African American patients in 32, or 71%, of the affordability and efficiency measures, mostly related to readmissions. Read full story Source: Becker Hospital Review, 29 February 2024
  22. News Article
    Almost 70,000 children are missing out on mental health care they should be eligible to receive as the NHS falls short of key targets, The Independent has revealed. An internal analysis, seen by The Independent, shows in England the NHS has fallen short of a target, set in 2019, for 818,000 children to receive at least one treatment session from Child and Adolescent Mental Health Services (CAMHS) in 2023. The actual number of children who received treatment in the 12 months to December was 749,833, falling short of the target by around 9%. The figures came as the government announced this week it would expand the number of early access mental health hubs for children to cover 50% of the country by 2025. However, campaigners urged ministers to commit to covering the entire country to help “turn the tide on the crisis” in children’s mental health services. The NHS analysis shows, as of December, CAMHS in the South West was furthest away from its targets with 78% of children seen out of those eligible. In London, 80% of the target was achieved and in the North West 105%. Laura Bunt, chief executive at YoungMinds, said: “Referrals to mental health services are at a record high with more young people than ever in need of support with their mental health. We know that many young people are struggling in the aftermath of the pandemic, facing intense academic pressure to catch up on lost learning, a cost of living crisis and increasing global instability. “Every young person should be able to access mental health support when they need it, but too many don’t get it until things get much worse. Services continue to be significantly underfunded and the number of young people receiving treatment falls woefully short of what is needed. To turn the tide on this crisis, the government must prioritise young people and their mental health by investing in prevention and early intervention.” Read full story Source: The Independent, 2 March 2024
  23. News Article
    Scores of potentially dangerous nurses and midwives could be working in the NHS and putting patients at risk as their cases sit in a growing backlog of misconduct, Hundreds of accusations against staff are being progressed without a full investigation, a Nursing and Midwifery Council (NMC) whistleblower has alleged, risking false sanctions or rogue nurses being wrongly cleared if the cases collapse. Overall there are more than 1,000 outstanding cases against healthcare staff for a hearing, including 451 that have not even been allocated a lawyer to vet. In 83 of the more serious allegations, the accused staff have been put under restrictions but could still be working with patients. The NMC whistleblower has claimed the figures expose a hidden backlog of “under-investigated” allegations, with 451 cases against nurses and midwives still needing to be reviewed by lawyers. These could include nurses who are innocent but are awaiting a hearing, with one “stuck in the void” for eight years, the source added. The whistleblower whose allegations prompted The Independent’s investigations has raised repeated concerns to the Professional Standards Authority (PSA), which regulates the NMC, over the hidden backlog, which was only uncovered through a freedom of information request. However the PSA has not used its powers to trigger a review. The whistleblower warned the public is being left at risk of harm, while nurses and midwives could face miscarriages of justice. “The NMC’s desperation to hide these figures has caused it to make dangerous decisions including creating a surge team of colleagues from across the organisation to review these cases with only minimal training,” the whistleblower said.“It is proposing to mass outsource these reviews to a firm of lawyers who have never undertaken this kind of work before.” Read full story Source: The Independent, 3 March 2024
  24. News Article
    Poorer people find it much harder to access NHS care than the well-off and have a worse experience when they do get it, research by the health service’s consumer watchdog has found. Those on the lowest incomes have much more difficulty getting a GP appointment, dental care or help with mental health problems, according to a survey by Healthwatch England. They are also more likely to feel they are not listened to by a health professional and not involved in key decisions about their care compared with those who are financially comfortable. The links between poverty and ill-health are well known, but the Healthwatch findings show that the worse-off also face the disadvantage what the watchdog called barriers to obtaining healthcare when they need it. The findings have prompted fears that the NHS is too often a “two-tier service” with access closely related to wealth, and calls for it to do more to make services more accessible to everyone. Healthwatch’s survey of 2,018 people aged 16 and over in England, which was a representative sample of the population, found that: 42% of those who described their financial situation as “really struggling” said they had trouble getting to see a GP, double the 21% of those who were “very comfortable”. 38% of the worst-off found it hard to get NHS dental care, compared with 20% of the better-off. 28% of the very poor had difficulty accessing mental health treatment, whereas only 9% of the very comfortable did so. Read full story Source: The Guardian, 4 March 2024
  25. Content Article
    Using experiences of care from over 10 million people collected over the past ten years, Healthwatch England presents a bold vision for the NHS in 2030. In a new report, Healthwatch outlines what they think the NHS should be in six years and how it can get there. The vision calls for a focus on three key themes: Making the NHS easier to access and navigate. Tackling health inequalities.  Building a patient-centred culture. 
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