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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
    Frontline staff often perceive event reporting as a black hole where no information exits once it enters. Join Andy Moyer, BSN, RN-BC, patient safety informatics specialist at Penn State Health Milton S. Hershey Medical Center, where he will help you tackle this perception by providing reporters better feedback. Moyer will also demonstrate ways to increase the quantity and quality of reported events. Register
  2. News Article
    The antibody drug Evusheld is effective for protecting clinically extremely vulnerable people from Covid-19, including its omicron variants, a preprint study has reported. The prophylactic treatment, manufactured by AstraZeneca, is a combination of two long acting antibodies (tixagevimab and cilgavimab). It is given as two separate, sequential intramuscular injections in the same session and can be administered in the community. A research team, led by the University of Birmingham alongside academics from King’s College London and the UK Health Security Agency, carried out a systematic review and meta-analysis to examine its effectiveness in immunocompromised patients. The paper examined the outcomes among 24 773 immunocompromised participants across 17 international studies, 10 775 of whom received Evusheld. Overall, it reported that the treatment was 86% effective for preventing covid specific death, 88% effective in preventing intensive care admission, effective in preventing hospital admission, and 40% effective in preventing Covid-19 infection. The study’s senior investigator, Lennard Lee, senior research fellow at the University of Birmingham and academic medical oncologist at the University of Oxford, said, “There is strong evidence emerging across the world that this approach of using prophylactic antibody therapies in combination with vaccination is a revolutionary approach to safeguard the most vulnerable patients this winter. The science and data suggest that it would be a successful approach for many cancer and immunocompromised patients at the highest level of risk.” Evusheld is already being given to immunocompromised patients in countries including the United States, France, and Israel, but the UK government is waiting for more data on the duration of protection it provides against omicron and its subvariants before deciding whether it should be used. Read full story Source: BMJ, 8 November 2022
  3. News Article
    Responding to a backlash from pain patients in the USA, the Centers for Disease Control and Prevention (CDC) have released updated guidelines that offer clinicians more flexibility in the way they prescribe opioids for short- and long-term pain. The new recommendations eliminate numerical dose limits and caps on length of treatment for chronic pain patients that had been suggested in the landmark 2016 version of the agency’s advice, which was aimed at curbing the liberal use of the medication and controlling a rampaging opioid epidemic. Those guidelines cautioned doctors that commencing opioid therapy was a momentous decision for patients. Parts of that nonbinding document were widely misinterpreted, resulting in unintended harm to patients who were benefiting from use of opioids without much risk of addiction. Patients reported they were rapidly tapered off medication by doctors or saw their medication abruptly discontinued, the CDC acknowledged in the new document. The new 100 pages of guidance — which remain only recommendations for doctors, nurse practitioners and others authorised to prescribe opioids — emphasize returning the focus to the caregiver and patient deciding on the best course of treatment. Read full story (paywalled) Source: The Washington Post, 3 November 2022
  4. News Article
    The death of a three-day-old baby could have been avoided if medical professionals had acted differently, a coroner concluded. Rosanna Matthews died three days after being delivered at Tunbridge Wells Hospital in Kent in November 2020. The hospital trust apologised, saying the level of care for Ms Sala and her daughter “fell short of standards”. Ms Sala told the inquest midwives were "bickering" and appeared confused during her labour. She claimed that if she had been allowed to start pushing when she wanted to, instead of waiting as midwives advised, Rosanna would have lived. Rachel Thomas, then deputy head of gynaecology and midwifery, said there had been "errors in communication". Following the conclusion of the inquest, the coroner ruled Rosanna died following a “prolonged period of avoidable hypoxia”, which led to brain damage. The coroner, sitting in Maidstone, also found midwives at the hospital failed to recognise that Rosanna was already unwell with congenital pneumonia. Ms Sala said her daughter could have lived had medical professionals acted differently on the day of her birth. Read full story Source: BBC News, 8 November 2022
  5. Content Article
    This download is the second of three chapters of a book which complements the Chartered Institute of Ergonomics and Human Factors' Healthcare Learning Pathway and is intended as a practical resource for students.
  6. Content Article
    With emergency departments beyond capacity throughout the country, some hospitals have been trialling an approach of moving a set number of patients into inpatient wards each hour, regardless of bed availability. Is this a viable solution to the problems faced throughout the system? Dr Louella Vaughan assesses the evidence and argues for further caution before rolling out such a model.
  7. News Article
    Cases of mouth cancer in the UK have increased by more than one-third in the last decade to hit a record high, according to a new report. The number of cases has more than doubled within the last generation and previous common causes like smoking and drinking are being added to by other lifestyle factors. According to the Oral Health Foundation, 8,864 people in the UK were diagnosed with the disease last year – up 36% on a decade ago, with 3,034 people losing their life to it within the year. This is an increase in deaths of 40% in the last 10 years, and a 20% rise in the last five. Dr Nigel Carter, the chief executive of the Oral Health Foundation, said: “While most cancers are on the decrease, cases of mouth cancer continue to rise at an alarming rate". Survival rates for mouth cancer have barely improved in the last 20 years, partly because so many cases are diagnosed too late. Just over half of all mouth cancers are diagnosed at stage four – where the cancer is at its most advanced. The findings from the Oral Health Foundation have been released to coincide with November’s Mouth Cancer Action Month. The goal of the Oral Health Foundation is to improve people’s lives by reducing the harm caused by oral diseases – many of which are entirely preventable. Read full story Source: The Independent, 9 November 2022
  8. News Article
    Abortion access is a “fundamental” part of women’s healthcare the government’s women’s health ambassador has warned. Dame Lesley Regan, who was appointed as Women’s Health Ambassador by the Government in July, has said in answer to questions from The Independent about the voting records of ministers: “I think it’s really important that we never ever get complacent about freedom of choice. “Now what my view is about whether abortion is good or bad is really irrelevant. My job is to tell the Prime Minister if he’ll listen and the Secretary of State that it [abortion] is an absolutely fundamental part of women’s healthcare." “Because I’ve done so much work overseas during my career, what I know is that if you make it difficult to access, or you make it illegal, the problem doesn’t go away but women die as a result.” Her comments come after it was revealed this week that the prime minister and senior members of his government have voted against boosting access to abortions or have opted out of key votes. More than a third of the government’s current cabinet voted against early medical abortion at-home measures rolled out in the wake of the pandemic being made permanent. The Department for Health and Social Care’s minister for women, Maria Caufield, who has been granted responsibility for abortion care, has previously voted to curtail access rights. Earlier this year The Independent revealed women seeking abortions in the UK are having to travel hundreds of miles to access care as “untenable” waiting times put unsustainable pressure on services. Read full story Source: The Independent, 8 November 2022
  9. News Article
    Routine screening for bipolar disorder should be ingrained into the NHS, alongside specialist training to help identify the condition and reduce the average nine-and-a-half-year wait to get a diagnosis, experts say. A report by the Bipolar Commission, which brings together academics and other experts in the field, also recommended appointing a national director of mood disorders to ensure everyone has access to a 12-week psychoeducation course, and a specialist doctor to oversee their prescriptions and ongoing care. More than 1 million people in the UK are estimated to have bipolar disorder, which leads to extreme changes in mood and energy levels far beyond most people’s experiences of feeling happy or a bit down. Yet many spend years chasing a diagnosis, or having been misdiagnosed with depression, meaning they cannot access key treatments such as lithium and lamotrigine that help to stabilise mood. According to the report, which was based on an 18-month programme of interviews, surveys and desktop research, many people face a “dangerous” delay in getting diagnosed, with an average wait of nine and a half years. During this time, just over one in three people claimed to have attempted suicide, while those who were misdiagnosed were also more likely to be repeatedly admitted to hospital, the report found. Even once a diagnosis of bipolar disorder is made, the current way most patients are treated – where they are only referred to a psychiatrist if they become seriously unwell – is failing, says Prof Guy Goodwin, emeritus professor of psychiatry at the University of Oxford and co-chair of the commission. “Psychiatric services see people when they are acutely ill … but, once recovered, people are discharged back to the care of their general practitioner. And that model we simply think doesn’t work,” Goodwin said. Read full story Source: The Guardian, 8 November 2022
  10. Content Article
    Bipolar UK's 'Bipolar Minds Matter' report calls for an immediate restructure of the healthcare system that is failing millions affected by bipolar, and puts forward the case for developing a dedicated care pathway so that people with bipolar can have access to specialist treatment and continuity of support over a lifetime. 
  11. News Article
    A health visitor wrote to housing officials expressing concern about conditions in a rented flat months before a two-year-old died after his exposure to mould. An inquest in Rochdale is investigating the death of toddler Awaab Ishak who lived with his mother and father in a one-bedroom housing estate flat managed by Rochdale Boroughwide Housing (RBH). Awaab’s father, Faisal Abdullah, first reported the damp and mould in autumn 2017, a year before the birth of his son. He made numerous complaints – phoning and emailing – and requested re-housing. In December 2020 Awaab developed flu-like symptoms and had difficulty breathing. He was given hospital treatment and then discharged. Two days later his condition at home worsened and he was seen at Rochdale urgent care centre where he was found to be in respiratory failure. He was transferred to Royal Oldham hospital where, upon arrival, he was in cardiac arrest and died. It was just a week after his second birthday. A pathologist told the inquest that the child’s throat was swollen to an extent it would compromise breathing. Exposure to fungi was the most plausible explanation for the inflammation. Lawyers for the family say the inquest will consider a number of matters including concerns about mould and damp and how they were dealt with. It will also look at the sharing of information between agencies and how the family’s cultural and language requirements were taken into account. Officials from RBH have yet to give evidence at the inquest but a statement was provided to the coroner on Tuesday in which RBH admits it “should have taken responsibility for the mould issues and undertaken a more proactive response”. Read full story Source: The Guardian, 8 November 2022
  12. News Article
    An audit conducted by an acute trust has found more than half the patients taken to one of its hospitals by ambulance were deemed “inappropriate for conveyance”. The assessment at Scarborough Hospital in Yorkshire, obtained by HSJ through a freedom of information request, examined a random sample of 100 patients, of which around 50 arrived by ambulance. Of those arriving by ambulance, half were deemed not to have required an ambulance conveyance. The Missed Opportunities Audit, which the trust said was “routine” and looked at a range of areas where the emergency department could streamline operations, said: “Fifty-two per cent of conveyance[s] by ambulances were deemed as inappropriate". “The reviewer did not have access to the policies of Yorkshire Ambulance Service, which may account for the low number of appropriate conveyances. However, based on clinical judgment for cases presenting by ambulance the arrivals should have presented either to a community service (33%) or via their own transportation methods (38%), as their documented clinical condition and social circumstances allowed for this.” Read full story (paywalled) Source: HSJ, 9 November 2022
  13. Content Article
    Visual of the Learning from Patient Safety Events (LFPSE) implementation timeline.
  14. Content Article
    Ambulance services in England are under immense pressure. In July 2022, all ambulance services in England declared REAP (Resource Escalation Action Plan) level four, reflecting potential service failure. Volumes of calls to 999 are increasing, patients in distress and pain are waiting longer for help to reach them, and ambulance teams feel unable to do their job well. The new Secretary of State for Health and Social Care has previously named cutting ambulance waits as his number one priority. As he takes up the role for the second time, he will again need to include ambulances in his list of priorities for the health and care system. Steps taken to date to help address the underlying issues have not yet had an impact on the pressures facing ambulance services. This analysis from The Health Foundation looks at ambulance service performance and explores the contributing factors and priorities for improvement.
  15. Content Article
    An HSIB guest blog post from Henrietta Hughes introducing her vision for her new role as Patient Safety Commissioner.
  16. News Article
    The health board in the Scottish Borders has said it is monitoring "unseasonably high" numbers of scarlet fever cases in the region. Parents have been asked to be aware of the symptoms so that early treatment with antibiotics can be given. Scarlet fever is a bacterial illness that mainly affects children under 10 but people of any age can get it. NHS Borders said it would usually clear up after about a week but anyone who thinks they or a child may have it has been asked to contact a GP for a proper diagnosis and appropriate treatment. "Due to the contagious nature of scarlet fever, if you or your child has the illness, please stay at home for at least 24 hours after starting treatment with antibiotics," it added. Read full story Source: BBC News, 7 November 2022
  17. News Article
    Thousands of hospital surgeries are likely to be cancelled as NHS leaders prepare for unprecedented strike action, The Independent has been told. Most operations apart from cancer care are likely to be called off when nurses take to the picket line, with NHS trusts planning for staffing levels to be similar to bank holidays. Multiple sources say they are almost certain that the upcoming Royal College of Nursing ballot will result in strike action. Results are expected to be finalised on Wednesday. “Trusts are looking at the totality of it. It’s the waiting list that is going to be hit, massive questions over waiting lists, and we’re going to lose days of activity in terms of addressing that growing pressure. “The more we see strike action the harder it is, the risk is [that] the rate of recovery [of waiting list] slows.” They added: “The unions normally provide bank holiday cover and maintain emergency service basically.” Read full story Source: The Independent, 7 November 2022
  18. News Article
    A teenager died after a breathing tube was possibly squashed by a wheel of her hospital trolley during emergency surgery, an inquest has heard. Jasmine Hill, 19, had a cardiac arrest shortly after undergoing a procedure on her neck at Gloucestershire royal hospital in Gloucester. The inquest heard that a report commissioned by lawyers acting for Hill’s family referred to the tube being “squashed by the wheel of a trolley”. Hill, from Cirencester, had been readmitted to the hospital after her neck became swollen five days after a thyroidectomy – the removal of all or part of the thyroid gland – in September 2020. Doctors thought the site of the surgery in Hill’s neck, which was red and swollen, may have become infected and it was decided the wound should be cleaned under general anaesthetic. The procedure took less than an hour and the teenager went into cardiac arrest shortly after she was moved by staff from the operating table to a bed. Gloucestershire coroner’s court heard an endotracheal tube, which supports breathing, was positioned behind Hill’s head and away from her neck, fixed to a holder and connected to the ventilator. The assistant Gloucestershire coroner Roland Wooderson asked Dr Hiro Ishii, who carried out the procedure, whether he was aware that the anaesthetist had checked the position of the endotracheal tube. Ishii replied: “I didn’t make a formal inquiry at that stage.” Read full story Source: The Guardian, 7 November 2022
  19. News Article
    A new pill that could prevent pre-eclampsia has become the first pregnancy drug to be fast-tracked for development by the UK’s drug regulator. Scientists at MirZyme Therapeutics, a biopharmaceutical company, believe they have developed a drug that when given to women from 20 weeks of pregnancy could stop them developing the condition. Pre-eclampsia endangers the lives of thousands of expectant mothers and their babies in the UK each year, and has no therapeutic options. Globally, it affects between 2% and 8% of pregnancies and kills up to half a million babies and 100,000 women a year. MirZyme Therapeutics has been awarded an innovative licensing and access pathway (ILAP), or so-called innovation passport, by the UK’s Medicines and Healthcare products Regulatory Agency (MHRA). The passport was established in January 2021 to expedite access to essential new drugs at the height of the Covid pandemic. It is granted to medicines that address the needs of patients with life-threatening and unmet medical needs, with a view to getting the drug to the market as quickly as possible. Read full story Source: The Guardian, 8 November 2022
  20. Content Article
    Inhalers are a key treatment for respiratory conditions, with approximately 60 million dispensed in England every year. However, inhalers are not always used in an optimal way, which can lead to poor disease control and avoidable deaths. Inhaler emissions account for approximately 3% of the NHS carbon footprint. The propellant used in metered dose inhalers is responsible for most of these emissions. Alternative options with a significantly lower carbon footprint exist, such as dry powder inhalers. The UK has a higher metered dose inhalers prescribing rate compared with other European countries. These countries have demonstrated that safe and effective care can still be delivered using other inhaler devices. Wyre Forest Health Partnership (WFHP) was formed from a merger of five GP practices and now comprises of six sites across Worcestershire with over 50 doctors, 200+ staff, and more than 73,000 patients. WFHP identified that, in line with the UK, they too had high prescribing rates for metered dose inhalers, and decided to act – to improve the health of their respiratory patients, while reducing their environmental impact. This case study shows what they did.
  21. Event
    until
    From July 2022, all NHS trusts providing acute and mental health services will need to join a provider collaborative, with these collaboratives forming a universal part of the provider landscape. Working within a challenging NHS environment – struggling with record high waiting lists and a limited workforce – provider collaboratives offer an opportunity to make efficiencies whilst improving service delivery. As providers move from a mindset of competition to one of collaboration, they must come together to deliver better services and improve care pathways. However, the purpose and form of these collaboratives can vary considerably across England and important decisions remain over the governance and accountability arrangements of these new collaboratives. Join the King's Fund for this digital virtual conference bringing together leaders from across collaboratives to explore this new approach to service delivery. The event will explore what collaboration models have been successful before and the barriers they overcame. What can we learn from these as new collaboratives are set to take shape? Register
  22. Content Article
    This guide is aimed at policymakers and communicators whose efforts may be frustrated by false narratives and misinformation. In healthcare, that can apply to important issues such as vaccination and mask-wearing, as well as to spurious 'cures' for serious illnesses. But the techniques explored in the guide can also apply to more day-to-day matters such as handwashing in healthcare settings. The starting point is the 'wall of beliefs' - the various influences from which we construct our belief systems, and, to some extent, our personal identities. The point here is that belief is not simply built on facts. It also comes from social conventions, peer pressure, religious faith and more. The guide offers a strategy matrix, based on understanding how strongly or weakly beliefs are held, and whether the resulting behaviour is harmful or not. A corresponding set of tactics looks at incentives and barriers for desired behaviour, along with communications that can address harmful beliefs without backing the intended audience into a corner.
  23. News Article
    Unpaid carers in Northern Ireland are suffering from "shocking levels of poor health", according to the charity Carers NI. In a survey of more than 1,600 unpaid carers across Northern Ireland, more than a quarter of respondents described their mental health as bad or very bad. One in five carers said the same about their physical health. The survey also found some 40% had not had a break from caring during the previous year and 23% said support services in their area did not meet their needs. Tracey Gililand, from Portadown, cares for her two disabled sons and said families like hers have been all but forgotten since the beginning of the pandemic. "Carers are still having to ask for the full return of much-needed day care and respite services and it feels like we've been left to paddle our own canoes with no help," she said. "No one knows our struggles, the many sleepless nights and exhaustion during the day. The impact on carers' mental health. The isolation that families like us experience that no one else sees," Ms Gililand explained. Carers NI said it has called for a legal right to social care support for all unpaid carers, the appointment of an independent carers' champion to advocate for carers to government, and wider transformation of the health system. Craig Harrison from the charity said carers had been "driving themselves into the ground", and were physically exhausted and in a state of constant anxiety. Read full story Source: BBC News, 8 November 2022
  24. News Article
    NHS England is investigating a “potential serious incident” in its flu programme following concerns that people aged 65 and over are being given a vaccination jab known to be ineffective for this age group. Details of the investigation were set out in a letter by NHS England’s South East regional team. The letter, seen by HSJ, said: “The NHS regional direct commissioning team are investigating reported administration of QIVe flu vaccine to patients aged 65 years or older by a number of primary care providers (primary care and pharmacy) across the region. QIVe is not recommended for use in this age group due to its poor effectiveness.” It said officials were contacting practices and pharmacists directly where there was a record of QIVe vaccine having been given to the older age cohort to identify whether this is a recording coding error, or a genuine administration of QIVe. Initial investigations “suggest a mixture of both”, it said. The letter added: “If any patient 65 or over has received QIVe, we will be asking the practice or pharmacist to treat this as an incident. Patients will need to be contacted, informed of the error, its potential implications and offered the opportunity to receive a vaccine which is appropriate for their age group." It is unclear how many patients have been given the wrong jab. Read full story Source: HSJ, 8 November 2022
  25. News Article
    Mental health patients are being held “unlawfully” in A&Es across the country as long waits for care and beds force staff into “fudging” the law, The Independent has been told. The University Hospital of North Midland Trust has been sanctioned by the Care Quality Commission (CQC) for holding mental health patients without any legal authority. However, experts have told The Independent the problem is widespread and occurs across every emergency department in the country with some patients waiting “days” and even “weeks” in A&E. Leaders at Barking, Havering and Redbridge NHS Trust have raised repeated concerns in recent months over patients waiting days in their A&E for mental health care. The CQC raised concerns about the assessment of mental health patients at UHNM following an inspection in October and served the trust with a warning notice. In a letter seen by The Independent, the CQC said two patients were “restricted within hospital unlawfully”. It said although staff were working in the patient’s best interests in both cases it was clear that legal procedures “were not being followed”. “Therefore, this can be seen as a significant infringement of any personal or welfare,” it said. Read full story Source: The Independent. 8 November 2022
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