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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    The proportion of newborn babies receiving a timely health visitor check-in has fallen sharply, with one in five missing out in the most recent statistics available. Official data reveals that only 82.6% of babies received a new birth visit within their first fortnight in 2021-22, as is recommended, and in the fourth quarter of the year it dropped as low as 79.3%. This is the lowest proportion recorded in recent years in the annual dataset on health visitor service delivery metrics, published by the Office for Health Improvements and Disparities. According to the NHS website, a health visitor new birth visit is supposed to take place between 10 and 14 days after birth and is designed to offer advice on issues including safe sleeping, vaccinations, infant feeding, infant development, and adjusting to life as a parent. Kate Holmes, head of support and information at charity The Lullaby Trust, said: “Safer sleep saves babies’ lives and all families should be given advice on how to reduce the risk of sudden infant death syndrome for their baby. The new birth visit is a key opportunity for health visitors to talk to families about safer sleep and to provide them with information and support that takes their individual and family circumstances into account.” Read full story (paywalled) Source: HSJ, 7 November 2022
  2. News Article
    The Medicines and Healthcare products Regulatory Agency (MHRA) has launched its seventh annual campaign urging clinicians and patients to report any suspected side effects or adverse incidents pertaining to medicines and medical devices. The global campaign involves regulators from more than 80 countries and aims to promote public and sector engagement in actively improving patient safety. Once flagged to the MHRA’s Yellow Card scheme, any suspected adverse incidents or risks are catalogued and investigated by the regulator – since being established in the mid-sixties, the initiative has identified, and dealt with, many safety concerns related to medicines and medical technologies, improving patient safety and strengthening the clinician-user relationship in the health sector. Phil Tregunno, MHRA Deputy Director of Patient Safety Monitoring, said: “Every report made by a patient, a healthcare professional, or a carer plays a key role in gaining knowledge about the risks of medicines and medical devices in clinical use and allows rapid, targeted action to be taken to minimise harm and ensure that the benefit-risk remains favourable. “Reporting suspected side effects and adverse incidents to the Yellow Card website is not just about the individual involved, it helps to improve the safety of medicines and medical devices for all patients. By reporting, you are part of the solution – and you may be helping to protect the most vulnerable, at-risk groups from potential harm. “If you, your child, or a patient in your care experiences a suspected side effect or adverse incident relating to a medicine or medical device, it is essential that you report it to us promptly. The faster you report, the likelier it is that we can intervene and prevent others from experiencing untoward, serious, life-altering, and occasionally life-threatening issues.” You can report any potential side effects, adverse incidents or risks by visiting the Yellow Card scheme’s website. Read full story Source: National Health Executive, 7 November 2022
  3. Content Article
    The investigation and tribunal hearing of Dr Manjula Arora generated significant anger and anxiety among the medical profession. The case raised once again the perception of a regulatory process lacking in fairness; of a system in which the stakes seem much higher if you are a black and minority ethnic doctor. The General Medical Council (GMC) acknowledged that strength of feeling, making clear it would not oppose Dr Arora’s appeal against the sanction and commissioning a review of the case to understand lessons to be learned for future cases.
  4. Content Article
    The General Medical Council (GMC) makes it clear that doctors in the United Kingdom are “personally accountable for [their] professional practice and must always be prepared to justify [their] decisions and actions.” It expects them to comply with a set of obligations, periodically updated, in a series of domains including safety and quality, skills and performance, and maintaining trust. But who is the GMC accountable to?  Fundamental questions need to be asked about who health regulators are accountable to, say Martin McKee and Scott L Greer in this BMJ opinion piece.
  5. Content Article Comment
    @Aoife McCarthy Hi. The link should now work.
  6. Content Article
    Please help the Campaign Against Painful Hysteroscopy uncover the circumstances, quantify the contributing factors, and evidence the consequences of painful and distressing hysteroscopies. The survey is anonymous. The results will be put in the public domain to be used to help improve hysteroscopy services for future patients.
  7. Content Article
    The aim of this study was to measure the impact of post-acute sequelae of COVID-19 (PASC) on quality of life, mental health, ability to work and return to baseline health in an Irish cohort. It found that patients with PASC reported prolonged, multi-system symptoms which can significantly impact quality of life, affect ability to work and cause significant disability. Dedicated multidisciplinary, cross specialty supports are required to improve outcomes of this patient group.
  8. Content Article
    For specialist treatment, Palestinians often need to be referred to a hospital outside Gaza – then apply for a travel permit. Tight budgets and restrictions mean few are granted. Int this Guardian article, one woman details the obstacles she has faced.
  9. News Article
    Patient care is still being undermined at NHS mental health trusts and social care providers that were hit by a major cyber attack in August, doctors have warned. Three months after the major attack wiped out NHS systems, patients’ records are missing, safety has been compromised, and medication doses are at risk of being missed amid ongoing “chaos”, i News has been told. Dr Andrew Molodynski, mental health lead at the British Medical Association, said the prolonged systems failure has damaged care because records are “integral to patients’ safety”. Mental health patients’ records and safeguarding alerts have not been available in some trusts since 4 August, when NHS software provider, Advanced, was hit by a ransomware attack which targeted its Carenotes records system. A total of 12 NHS mental health trusts have been impacted by the cyber attack, potentially impacting tens of thousands of patients as well as social care providers. According to Advanced’s own hazard log spreadsheet, seen by i News, the risks associated with disruption to its server include “medication doses missed”, “required number of carers not met”, “basic needs not met, such as nutrition and personal care”, and “health needs not met, such as wound care and physical support”. Advanced said: “We recognise that the restoration process has taken longer than we had initially anticipated and we have sought to communicate as clearly and transparently as we have been able.” It said planned dates for restoring the system for each client has been communicated directly and that the “overall restoration programme remains on track”. Read full story Source: i News, 4 November 2022
  10. News Article
    US influenza hospital admissions have hit the highest rate in a decade as vaccinations sag, US officials say. They said adults have received five million fewer influenza jabs this year compared with the same time last year. Health experts are worried a so-called tripledemic of flu, respiratory syncytial virus (RSV) and coronavirus could swamp hospitals this winter. At least 730 people have died of flu this year, according to the Centers for Disease Control and Prevention (CDC). While older people are the most vulnerable age group, at least four children are among the dead. CDC data shows there have been at least 1.6 million flu cases overall and some 13,000 people have been taken to hospital. This season's severity has not been matched at this point in the year since the H1N1 swine flu pandemic hit the US in 2009. "There's no doubt we will face some challenges this winter," Dawn O'Connell, the US Department of Health and Human Services' (HHS) assistant secretary for preparedness and response, said at a media briefing on Friday. Read full story Source: BBC News, 5 November 2022
  11. Content Article
    Racism is unacceptable and it has no place in health and care. But we know that it exists and that the impact on staff can be devastating. All registered professionals have responsibility under the Nursing and Midwifery Council (NMC) Code to challenge discriminatory behaviour, creating an environment where people are treated as individuals and with dignity and respect. This resource is firmly rooted in our professional Code and it is designed to support nurses, midwives and nursing associates, providing advice on the action you can take if you witness or experience racism. It also supports those in leadership roles to be inclusive leaders. This document provides practical examples of how, as nursing and midwifery professionals, you can recognise, and challenge racial discrimination, harassment, and abuse. It also highlights other useful resources and training materials that will support you to care with confidence. This document is a resource for individuals at all levels. This resource does not replace existing NHS England policies and procedures for speaking up and managing racism. It is a resource to support best practice in line with organisational policies and procedures.
  12. Content Article
    With a single drug in the UK currently costing £340,000 per patient per year, or a gene therapy in the USA being costed at $1.2million, who should get such treatments, and how can we begin to afford them? Should we all be entitled to timely mental health therapy? How should we care for our old? As we grapple with the world's worst pandemic for a century, our minds are on our health more than ever. But what should we rightfully expect of doctors? In this original and thought-provoking book, t. Informed by patient stories and data from across the world - from US big pharma to Britain's NHS - this is an urgent and often moving examination of our most important asset: our health.
  13. News Article
    Almost 90% of those living with Long Covid in Ireland have not returned to their pre-Covid level of health, according to a new report. The study of 988 participants was carried out by APC Microbiome Ireland, a research centre based at University College Cork (UCC), in conjunction with Cork University Hospital and Long Covid Advocacy Ireland. It found that more than two-thirds of participants in the study continued to experience fatigue, memory problems, chest pain, stomach upset, and muscle pain. Those surveyed also reported that they were suffering from new symptoms that had not been present before catching Covid. These included tinnitus (38%), mouth ulcers (28%), new allergies (16%) and sexual dysfunction (13%). They said these prolonged symptoms can significantly impact their quality of life, affect their ability to work and cause significant disability. Read full story Source: BBC News, 7 November 2022 Further reading and resources can be found in our dedicated area of the hub on Long Covid.
  14. News Article
    The biggest ever strike by nurses looks set to go ahead. The Royal College of Nursing is due to unveil the results of its ballot, which ended last week, in the next few days. The final results are being counted but RCN sources say a large majority of nurses have voted in favour of action in a dispute over pay. The RCN had recommended to its 300,000 members that they walk out. If strikes take place, they would affect non-urgent but not emergency care. The vote has involved a series of individual workplace-based ballots across the UK and if nurses do not back action at a local level it is possible some hospitals and services will not be involved. The government had appealed to nurses to "carefully consider" the impact on patients. But Pat Cullen, RCN general secretary and chief executive, said: "Huge numbers of staff - both experienced and newer recruits - are deciding they cannot see a future in a nursing profession that is not valued nor treated fairly. She added: "Our strike action will be as much for patients as it is for nurses. We have their support in doing this." Cabinet minister Oliver Dowden said the government had "well-oiled contingencies in place" for dealing with any strike action by nurses. Speaking on Sky News, Mr Dowden said essential services would be prioritised, "but of course there would be an impact as a result of a strike like that". Read full story Source: BBC News, 6 November 2022
  15. News Article
    A whistleblower at a mental health trust criticised over the deaths of three teenagers has said bosses ignored workers when they raised concerns. Christie Harnett and Nadia Sharif, both 17, and Emily Moore, 18, who were friends, all took their own lives within eight months of each other. The whistleblower said agency workers fell asleep on duty at Middlesbrough's West Lane Hospital and staff struggled "to keep children alive". The trust has apologised for failings. Reports into the women's care found 120 failings at Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), which ran the hospital, and other agencies. Speaking after the reports were published, the health trust worker, who did not wish to be identified, told the BBC staff were "ignored" when they tried to warn bosses about conditions in the hospital. "Staff repeatedly raised concerns with managers, some of the time we just didn't have enough staff to keep the children safe," the worker said. "We warned them something serious was going to happen, but they just ignored us. "Senior managers looked at numbers, rather than the skillset that staff actually had. "The agency staff would sometimes fall asleep on duty or watch the telly rather than engage with patients." Read full story Source: BBC News, 4 November 2022
  16. News Article
    Hysteroscopy Action says thousands of women are in extreme pain during and following the invasive procedures to treat problems in the womb, with many suffering for days. It says some are left with symptoms of post-traumatic stress and subsequently feel unable to have intimate relationships with partners. Others avoid important examinations such as smear tests. The group has written to Women’s Minister, Maria Caulfield, to raise its concerns. In its letter, it claims women are not always given the choice of intravenous sedation or general anaesthetic to reduce pain because of an NHS drive to cut costs. Some are given local anaesthetic which is often painful and doesn’t work. Others are given no drugs at all and expected to cope with distraction techniques - known as “vocal locals.” Hysteroscopy Action has urged Ms Caulfield to open more theatre space for women to have procedures under general anaesthetic as well as offering women the choice of intravenous sedation. Yet Hysteroscopy Action, which has been in touch with thousands of patients who have undergone such examinations, says women are not made aware of this. Last week RCOG President Dr Edward Morris, said it was “working to improve clinical practice around outpatient hysteroscopy”. He added: “No patient should experience excruciating pain and no doctor should be going ahead with outpatient hysteroscopy without informed consent.” "Hysteroscopy Action has collated more than 3,000 accounts of “brutal pain, fainting and trauma during outpatient hysteroscopy.” Hysteroscopy Action's spokeswoman, Katharine Tylko said: “We are counselling hundreds of patients with PTSD, who for various medical reasons find the procedure extremely painful, some even find it torturous." “This does not happen for other invasive procedures such as colonoscopy. We urge the Women’s Minister to act and are demanding an end to this gender pain-gap.” The letter, which has over 20 signatories, including Helen Hughes, Chief Executive of the Patient Safety Learning charity, Baroness Shaista Gohir, civil rights campaigner, and women’s rights activist, Charlotte Kneer MBE, calls for women to be given informed consent and choice about whether and what type of sedation they want. Read full story Source: Express, 6 November 2022 Read hub members experiences of having a hysteroscopy in the Community thread and Patient Safety Learning's blog on improving hysteroscopy safety.
  17. News Article
    NHS England is considering a substantive shift to a ‘payment by results’ model from April, in a bid to drive up elective activity. Under rules for this financial year, elective care is paid for through block contracts, with additional payments for areas that treat more patients, and supposed penalties for those that fall short. One well-placed source told HSJ there was “strong momentum” towards reviving PbR for elective care, which could mean trusts being paid purely for each unit of activity delivered, without a block contract element. There is a belief this could help drive up activity levels, which have remained below the levels recorded before the pandemic. Returning to PbR would be a controversial move, as many believe it drives competitive behaviour between providers and goes against the grain of collaboration within health systems. Other options for changes to the payment system being considered include increasing the rate of incentives and penalties. Read full story Source: HSJ, 4 November 2022
  18. Content Article
    Overprescribing effects patient’s experience of, and engagement with, health and care services. It results in unnecessary costs and harm to patients. Watch this short video from Steve Turner. Reflection and key learning points based on UK laws and guidelines.
  19. Content Article
    This is the first edition of the Patient safety assessment manual for primary care, which explains how to apply the Patient Safety Friendly Primary Care Framework. It comprises a set of standards that cover the different domains of patient safety. The Patient Safety Friendly Framework was developed by the WHO Regional Office for the Eastern Mediterranean to assess patient safety at a system level. The framework provides a means to determine the level of patient safety for the purpose of initiating a patient safety or quality improvement programme. The evaluation is voluntary and is conducted through self-assessment and an external peer review survey. The standards in the Patient Safety Friendly Primary Care Framework are based on international research and evidenced-based practices in primary care. To ensure the standards remain current, revisions will be made every three to four years. In this edition, the total number of standards is 19, made up of 125 criteria. Standards have been developed with consideration for their alignment with all WHO initiatives to promote safer care.
  20. Content Article
    You have the right to make a complaint about any aspect of NHS care, treatment or service The information on this NHS page will guide you through the NHS complaints process, as well as the core requirements for NHS complaints handling.
  21. News Article
    Lawyers acting for an NHS trust are being investigated over “gagging” clauses proposed in a settlement agreement with a whistleblower who raised concerns that mistakes by paramedics in the deaths of patients were being covered up. In June, the then health secretary, Sajid Javid, announced an NHS review into “tragic failings” by North East Ambulance Service after Paul Calvert went public with claims that reports into deaths were doctored to cover up failings by staff. The Guardian has learned that NEAS’s lawyers, Ward Hadaway, are also under scrutiny – by the Solicitors Regulation Authority (SRA) – over the terms proposed by the trust for his exit agreement. The agreement, offering him £41,000 in compensation, initially included confidentiality clauses relating to future disclosures. A SRA investigation does not mean there has been wrongdoing and it does not confirm or deny whether it is examining a solicitor. However, the Guardian understands that the regulator has been in contact with Calvert about the proposed agreement. Read full story Source: The Guardian, 3 November 2022
  22. Event
    This masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key learning objectives: Understanding the role of the Senior Information Risk Owner. Identifying information risks across the organisation. Working with others to mitigate the risk to patients, staff and organization. Confidence that all reasonable technical and organisation measure are in place. Giving assurance to the Board that risks have been considered, mitigated or owned. Understand the requirements of external confidence that policies, procedures are in place to deal with data breaches. Facilitated by Andrew Harvey IG Consultant BJM IG Privacy Ltd. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  23. 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. It will look at the case for change and how we can develop a culture of learning. Key learning objectives: share learning culture person centred care lifelong learning. The course is facilitated by Perbinder Grewal. Register hub members receive a 20% discount. Email info@pslhub.org for a discount code.
  24. Event
    RegisterThis course is suitable for anybody who deals with complaints as part of their job role, or anybody who may have to handle a complaint. This includes dedicated complaints teams & customer support teams and managers. The programme includes a section on handling complaints regarding Covid-19 - understanding the standards of care by which the NHS should be judged in a pandemic. A highly interactive and effective workshop to improve confidence and consistency in handling complaints. A simple model to facilitate effective responses will be shared and delegates will have the opportunity to practise the use of our unique AERO approach. Key objectives: Improved confidence in using mediation techniques to resolve challenging customer complaints. Use of a methodology to improve consistency in successfully addressing challenging customer concerns. Personal Action plan to take back to my role and my team. Complaints Resolution & Mediation (healthcareconferencesuk.co.uk) hub members receive a 20% discount. Email info@pslhub.org for a discount code.
  25. Event
    This one-day masterclass will focus on how to use behavioural insights and nudge theory to look at patient safety and safety culture. "Nudge Theory is based upon the idea that by shaping the environment, also known as the choice architecture, one can influence the likelihood that one option is chosen over another by individuals. A key factor of Nudge Theory is the ability for an individual to maintain freedom of choice and to feel in control of the decisions they make. " Nudge-type interventions have the potential for changing behaviours. We will look at examples of nudge theory use in healthcare and external organisations and how we can use these to improve patient safety and also to reduce inefficiency and waste. We will look at the type of interventions suitable for nudges and how to develop them. Key learning objectives: Behavioural insights. Nudge theory. Use of nudge theory to improve patient safety. Developing nudges. Opportunities for nudge-type interventions. Facilitated by Perbinder Grewal. Register hub members receive a 20% discount. Email info@pslhub.org for a discount code.
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