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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
    This one-day masterclass, facilitated by Glenys Hurt-Robson, Associate Facilitator, The Athena Programme, will support you to develop your role and responsibility as a Designated Safeguarding Officer / Designated Safeguarding Lead / Named Professional for safeguarding in your organisation. It will enable you to understand one or both of the child and adult abuse investigation processes under Working Together to Safeguard Children (2018) and / or the Care Act 2014. This course will connect emotionally with your safeguarding core. It will stimulate and support you as you reflect on the key responsibilities of the role and how these relate to your organisational context. Against a backdrop of current safeguarding legislation (Children Act 2004, Care Act 2014) it will help you examine your own role and the roles of others in the multi-agency world of protecting and supporting children and adults at risk. The skills and knowledge gained will raise your awareness of current risks and allow you to proactively develop your safeguarding role. The course will assist in building your resilience in dealing with allegations against staff and in-depth understanding of how to protect and support those involved. The content is based on current NHS Intercollegiate Documents - Roles and Competencies for Safeguarding and pitched at NHS level 4 for named professionals. Register
  2. Event
    This national conference looks at the practicalities of serious incident investigation and learning. The event will look at the development and implementation of the new Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) a version of which has now been published. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email nicki@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for a discount code. Follow on Twitter @HCUK_Clare #NHSSeriousIncidents
  3. News Article
    South West Ambulance has the longest waits in the country for people to get through to the operator. It takes almost a minute on average for ambulance control to answer 999 calls compared with just five seconds for the West Midlands service. Jean and Claire Iles called 999 six times to request an ambulance for Steven Iles' internal bleeding and two of their calls were unanswered for 10 minutes "He just looked at me and he just passed away before they could even get to him," 41-year-old Claire Iles said. "I rang about 4pm and said he has gone grey, and I said if you don't come now he is going to die, and it was still 20 minutes before the ambulance turned up." She was at home with her parents in Yate, near Bristol, when her father, Steve, 63, fell ill. It took 11 hours for a South West Ambulance crew to arrive, but Jean said by that time it was too late. Mr Iles died at 17:10 GMT on 19 March from a strangulated hernia that cut off the blood supply to his heart. The trust has apologised for the distress and anxiety caused but said it remained under "enormous pressure". Read full story Source: 4 November 2022
  4. Content Article
    Mike Fell, executive director of national cybersecurity operations at NHS Digital,, discusses the WannaCry cyberattack, teaching GP surgeries to up their game and how data can save lives.
  5. News Article
    A boss at a trust which was heavily criticised in a damning report says patients have lost confidence in the care they provide. Raymond Anakwe, executive director of East Kent Hospitals Trust, said regaining patient trust would be "possibly the largest challenge". He was speaking at a board meeting two weeks after a review found a "clear pattern" of "sub-optimal" care. Mr Anakwe said: "The reality is we have lost the confidence of our patients." He also said the trust has lost the confidence "of our local community and sadly also many staff". The trust's chief executive, Tracey Fletcher, told the meeting that she believed many staff thought "enough is enough", and that the trust has to be "brave" if it's to move forward. Stewart Baird, a non-executive director, said: "I think it's clear the buck stops here with the people sat round this table, and where there are bad behaviours in the trust, it's because we have allowed it. "Where people don't feel able to speak up, it's because we have not provided an environment for them to do that." Read full story Source: BBC News, 3 November 2022
  6. Content Article
    In 1999, the pivotal report “To Err is Human” by the Institute of Medicine led to sweeping changes in healthcare. This report outlined how blaming individuals does not change the underlying factors that contribute to medical errors. It also stated that blaming an individual does little to make the system safer – or prevent someone else from similar errors. It is unusual for a nurse to be charged criminally, when there is no intent to harm a patient. However, the recent trial in America of nurse RaDonda Vaught could set a precedent for future medical errors to be treated as criminal cases. The case may ensure that for every step that has been taken forward in patient safety, we have now taken two steps backwards. This article from Human Factors 101 looks at the case of RaDonda Vaught, the criminal trial and conviction, and discusses the impact this will have on healthcare.
  7. News Article
    The gap between the number of GPs per patient in richer and poorer parts of England is widening, according to analysis by University of Cambridge. The study for BBC Newsnight saw "stark inequalities" in GPs' distribution. Separate BBC research also found patient satisfaction on measures such as how easy a practice is to reach by phone is lower in deprived areas. The Department of Health and Social Care said it was focusing support on those who need it most. Earlier this year, public satisfaction with GP care - as measured by the British Social Attitudes poll - fell to its lowest level across England since the survey began in 1983. The fall was widespread across all income groups. The finding chimes with a Health Foundation analysis of official checks on the quality of services carried out by the Care Quality Commission (CQC). It found practices serving patients living in the most deprived areas are more likely to receive CQC ratings of "inadequate" and "requires improvement" than those serving patients who live in the most affluent areas. Read full story Source: BBC News, 4 November 2022
  8. News Article
    Ambulance trusts should review their ability to respond to mass casualty incidents and press commissioners for any additional resources they need, the report into the Manchester Arena bombing has said. Only 7 of the 319 North West Ambulance Service Trust vehicles available on the night of the attack, in 2017, were able to deploy immediately, the report said. It said experts believed that “such a situation would almost inevitably be replicated if a similar incident were to occur again anywhere in the country”, given current resources and demand. Ambulance trusts are now hugely more stretched than in 2017, with response times having significantly lengthened due to lack of resources. The second volume of the report from the inquiry, chaired by Sir John Saunders, published today, is critical of the emergency services’ response to the bombing which killed 22 people. NWAS “failed to send sufficient paramedics into the City Room [an area adjoining the Arena]” and did not use available stretchers to remove casualties in a safe way, it says. A key role for managing the incident – that of ambulance intervention team commander – was not allocated for half an hour. But it also raised issues of ambulance capacity and availability for major incidents involving mass casualties. “Around the UK, ambulance services are always ’playing catch up,’” it said, with no spare frontline capacity. With demand doubling over the last 10 years, the inability to respond to such incidents is only going to get worse – and lives will be lost if they do not attend the scene quickly and in sufficient numbers, the report said. Read full story (paywalled) Source: HSJ, 3 November 2022
  9. News Article
    GPs are breaching medical guidelines by prescribing antidepressants for children as young as 11 who cannot get other help for their mental health problems, NHS-funded research reveals. Official guidance says that under-18s should only be given the drugs in conjunction with talking therapies and after being assessed by a psychiatrist. But family doctors in England are “often” writing prescriptions for antidepressants for that age group even though such youngsters have not yet seen a psychiatrist, according to a report by the National Institute for Health and Care Research (NIHR), the NHS research body. The report linked the prescriptions to the long wait many young people, some self-harming or suicidal, face before starting treatment with NHS child and adolescent mental health services (CAMHS). Under-18s are prescribed the drugs for anxiety, depression, pain and bedwetting. The guidance on antidepressants has been issued by the National Institute for Health and Care Excellence (NICE), which advises the NHS on which treatments are effective. Referencing NICE’s recommendation of a two-step approval process, the NIHR study said “this often” did not happen. “No antidepressants are licensed in the UK for anxiety in children and teenagers under 18 years, except for obsessive compulsive disorder. Yet both specialists [psychiatrists] and GPs prescribe them. Thousands of children and teenagers in the UK are taking antidepressants for depression and anxiety. The numbers continue to rise and many have not seen a specialist.” Read full story Source: The Guardian, 4 November 2022
  10. News Article
    Ministers may order a public inquiry into mental health care and patient deaths across England because of the number of scandals that are emerging involving poor treatment. Maria Caulfield, the minister for mental health, told MPs on Thursday that she and the health secretary, Steve Barclay, were considering whether to launch an inquiry because the same failings were occurring so often in so many different parts of the country. They would make a final decision “in the coming days”, she said in the House of Commons, responding to an urgent question tabled by her Labour shadow, Dr Rosena Allin-Khan. An independent investigation found this week that that three teenage girls – Christie Harnett, 17, Nadia Sharif, 17, and Emily Moore, 18 – took their own lives within the space of eight months after receiving inadequate care from the Tees, Esk and Wear Valleys (TEWV) NHS mental health trust in north-east England. They died after “multifaceted and systemic failings” by the trust, especially at its West Lane hospital in Middlesbrough, the inquiry found. Allin-Khan pointed to a series of scandals that have come to light, often through media investigations, about dangerously substandard mental health care being provided by NHS services and also private firms in England, including in Essex and in Greater Manchester. “Patients are dying, being bullied, dehumanised, abused and their medical records are being falsified, a scandalous breach of patient safety,” Allin-Khan said. “The government has failed to learn from past failings.” Read full story Source: The Guardian, 3 November 2022
  11. Content Article Comment
    @Barbara Hercliffe The page appears to have been removed from the NHS Resolution website but the pdf is still available. I've updated the link Did-You-Know-Extravasation.pdf (resolution.nhs.uk)
  12. News Article
    The state of social care in England has “never been so bad”, the country’s leading social services chief has said, with half a million people now waiting for help. Sarah McClinton, president of the Association of Directors of Adult Social Services (ADASS), told a conference of council care bosses in Manchester: “The shocking situation is that we have more people requesting help from councils, more older and disabled with complex needs, yet social care capacity has reduced and we have 50,000 fewer paid carers.” Over 400,000 people rely on care homes in England and more than 800,000 receive care at home. But care services are struggling with 160,000 staff vacancies, rising demand and already tight funding for social care that is being squeezed by soaring food and energy inflation. About a third of care providers report that inability to recruit staff has negatively affected their service and many have stopped admitting new residents as a result. Last month the Care Quality Commission warned of a “tsunami of unmet care” and said England’s health and social care system was “gridlocked”. Problems in social care make it harder to free up beds in hospitals, slowing down the delivery of elective care. “The scale of how many people are either not getting the care and support they need, or are getting the wrong kind of help, at the wrong time and in the wrong place is staggering,” said McClinton, who is also director for health and adult services in Greenwich. “It is also adding to the endless pressures we see with ambulances and hospitals, and adding to the pressures we see in our communities, more people requesting help with mental health and domestic abuse.” Read full story Source: The Guardian, 2 November 2022
  13. Content Article
    In July 2022, Henrietta Hughes was appointed the first ever patient safety commissioner for England. The role was recommended in the Independent Medicines and Medical Devices Safety (IMMDS) review’s ‘First do no harm’ report, published in 2020, which explored issues relating to the use of Primodos, sodium valproate and pelvic mesh. Just a few weeks into her role as the first ever patient safety commissioner for England, The Pharmaceutical Journal spoke with Henrietta Hughes to find out more about her vision for patient safety in the NHS and where pharmacists fit into that.
  14. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include national developments, including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the HSIB Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and Covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code Follow on Twitter @HCUK_Clare #DeterioratingPatient
  15. Event
    This conference will focus on measuring, understanding and acting on patient experience insight, and demonstrating responsiveness to that insight to ensure patient feedback is translated into quality improvement and assurance. Through national updates and case study presentations the conference will support you to measure, monitor and improve patient experience in your service, and ensure that insight leads to quality improvement. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/patient-experience-insight or email nicki@hc-uk.org.uk hub members receive 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #PatientExp
  16. Event
    until
    Now, more than ever, the landscape of the health and care system in England is challenging and complex. Policy experts from The King’s Fund will help you gain a greater understanding of how the health and care system in England currently works and how it is changing. It will put this in the context of the current external environment by exploring the key issues in health and care, and will provide balanced and honest views about the pressures and opportunities the system faces in 2023. Taking place virtually over two days, this conference will provide you with the opportunity to interact with our experts and gain confidence working with colleagues throughout the system. Register
  17. Event
    The case for addressing poverty, its root causes and associated health inequalities is urgent and overwhelming. The Covid-19 pandemic has laid bare the harm caused by deprivation, and the cost-of-living crisis is likely to hit the poorest the hardest – leading to poorer health and lower social mobility. At this event, leaders across the NHS, local government, the voluntary, community and social enterprise (VCSE) sector, and those with lived experience will share learning on the role of the health and care sector in tackling the root causes of poverty. This King's Fund event will provide practical examples on how the health and care sector can effectively engage with partners across local government, the VCSE sector and business, to achieve meaningful progress on poverty and deliver services to the most excluded in society. You will hear about the role of NHS organisations as ‘anchor institutions’ and discuss how health and care organisations should use their influence and resources to poverty-proof services, address inequalities, and benefit the communities they serve. Register
  18. Event
    until
    Sir Mike Richards’ review of diagnostics, Diagnostics: recovery and renewal, which was commissioned in response to recommendations in the NHS Long-Term Plan, outlined a new diagnostic model for services. The review identified key enablers to drive and deliver much needed to change to optimise diagnostic capacity and improve efficiency, along with the need for a major expansion of the workforce and improved connectivity and digitisation across all aspects of diagnostics. Demand for almost all aspects of diagnostics has been rising year on year. The public’s familiarisation with swab testing and testing closer to home through the Covid-19 has provided a strong launch pad to change the approach to diagnostics in response to this rising demand This King's Fund event will explore what can be learnt from the NHS reponse to Covid-19, how partners are working to reshape diagnostic pathways through community diagnostic centres, point-of-care testing and increasing workforce capability and capacity. Register
  19. Content Article
    We need a public register to show if healthcare professionals are in the pay of industry – or more patients will suffer, writes Margaret McCartney following the publication of the Independent Medicines and Medical Devices Safety Review. Hospitals in England are meant to publish registers of interest of staff – but a 2016 study shows that only a minority give the details they should. A publicly accessible digital register, updated at least annually and compelled by the regulator, would create transparency and get rid of the huge amount of work that campaigners have had to do to untangle where conflicts lie. Declarations alone can’t sort the problems of conflicted medicine. But a public register would allow us to know whose advice isn’t independent. We will still need to be alert to the unintended consequences of a register, and research will be needed. The UK is lagging behind. Kath Sansom, a journalist who founded the Sling the Mesh campaign, told Margaret: “I had no idea that I couldn’t trust my doctor or surgeon to give the best advice. It is essential that medics declare industry funding.”
  20. News Article
    More than two-fifths of people in Britain suffer from some form of chronic pain by the time they are in their mid-40s, research suggests. Scientists have found that persistent bodily pain at this age is also associated with poor health outcomes in later life – such as being more vulnerable to Covid-19 infection and experiencing depression. The findings, published in the journal Plos One, suggest chronic pain at age 44 is linked to very severe pain at age 51 and joblessness in later life. Study co-author Professor Alex Bryson, of University College London’s Social Research Institute, said: “Chronic pain is a very serious problem affecting a large number of people. “Tracking a birth cohort across their life course, we find chronic pain is highly persistent and is associated with poor mental health outcomes later in life including depression, as well as leading to poorer general health and joblessness. “We hope that our research sheds light on this issue and its wide-ranging impacts, and that it is taken more seriously by policymakers.” Read full story Source: The Independent, 2 November 2022
  21. News Article
    Patients are not always getting the care they deserve, says the head of NHS England. Amanda Pritchard told a conference the pressures on hospitals, maternity care and services caring for vulnerable people with learning disabilities were of concern. She even suggested the challenge facing the health service now was greater than it was at the height of the pandemic. Despite making savings, the NHS still needs extra money to cope, she said. Next year the budget will rise to more than £157bn, but NHS England believes it will still be short of £7bn. Ms Pritchard told the King's Fund annual conference in London that demand was rising more quickly than the NHS could cope with. "I thought that the pandemic would be the hardest thing any of us ever had to do," she said. "Over the last year, I've become really clear.... it's the months and years ahead that will bring the most complex challenges." Read full story Source: BBC News, 2 November 2022
  22. News Article
    Just 10 trusts account for more than half of patients ‘inappropriately’ sent out of their area for a mental health bed – with dozens having to travel up to 300km, according to HSJ analysis. Official NHS data for adults shows these 10 mental health providers accounted for 9,485 “inappropriate” out of area placement bed days during July, out of 18,705 across the 44 trusts reported nationally. At one trust, Sussex Partnership FT, 40 placements were recorded as being between 200km and 300km away in that single month. The trust has revealed in board papers that four were sent to Glasgow. It has cited a shortage of capacity in the Kent and Sussex adult eating disorder service having led to 25 OAPs, and also said “quality concerns” had caused a temporary lack of acute beds in the county. Nationally, levels of “inappropriate” out of area placement – where people with acute mental health needs are sent up to hundreds of miles for a bed – are rising again, driven by quality failures, bed closures and staffing shortages. Read full story (paywalled) Source: HSJ, 3 November 2022
  23. News Article
    A damning report has highlighted failures in how NHS Tayside oversaw a surgeon who harmed patients for years. Prof Eljamel, the former head of neurosurgery at NHS Tayside in Dundee, harmed dozens of patients before he was suspended in 2013. The internal Scottish government report into Prof Sam Eljamel, which has been leaked to the BBC, said the health board repeatedly let patients down. It outlined failures in the way Prof Eljamel was supervised and the board's communication with patients. The report was commissioned last year over unanswered questions and concerns from patients Jules Rose and Pat Kelly. Mr Kelly has been left housebound and Ms Rose has PTSD after the neurosurgeon removed the wrong part of her body. After her operation in 2013, Ms Rose discovered that Prof Eljamel had taken out the wrong part of her body. He removed her tear gland instead of a tumour on her brain. She still has not been told exactly when health bosses knew he was a risk to patients. The latest Scottish government report said she should receive an apology. The written apology she received from the board last month said it was sorry she "feels" there has been a breakdown in trust. "I actually rejected the apology," she said. Ms Rose said she wanted the chairwoman of the health board to explain why it will not offer a "whole-hearted apology" for its failures. Scottish Conservative MSP Liz Smith called for a public inquiry, saying there had been a lack of accountability and the investigation had still not got to the truth. Read full story Source: BBC News, 3 November 2022
  24. News Article
    NHS England has revealed it estimates there are 5.5 million people on elective referral to treatment waiting lists, rather than the 7 million which is often reported. No figures have previously been given for the number of separate individuals, but many in politics, policy and the media have often indicated it is the same as the total number of entries on the RTT list – which hit 7 million in August. NHSE elective recovery chief Sir Jim Mackey, speaking at the King’s Fund annual conference in London yesterday, revealed an estimate for the first time of the number of individuals. Sir Jim said: “It’s actually 5.5 million people, but seven million entries on the waiting list. There are around a million and a half people, we think, who are on multiple times. So, it’s a lot more complicated than we all think.” He said it was not clear how many were patients waiting for genuinely separate issues or procedures, and how many were duplicates for the same pathway – essentially errors. Sir Jim said he hoped a new NHSE project would clarify the picture. He said: “Sometimes there are people on twice, where they need one thing then another thing. Other times it’s a bit more complicated… We’re just about to start a process with a handful of organisations to try and work out what that means.” Read full story (paywalled) Source: HSJ, 2 November 2022
  25. News Article
    Three teenage girls died after major failings in the care they received from NHS mental health services in the north-east of England, an independent investigation has found. “Multifaceted and systemic” failures by the Tees, Esk and Wear Valleys (TEWV) NHS trust contributed to the young women’s self-inflicted deaths within eight months of each other, it concluded. Christie Harnett died aged 17 on 27 June 2019 at the trust’s West Lane hospital in Middlesbrough. Nadia Sharif, also 17, died there six weeks later, on 5 August. Emily Moore, who had been treated there, died on 15 February 2020 at a different hospital in Durham. All three had complex mental health problems and had been receiving NHS care for several years. The investigation into their deaths, commissioned by the NHS, found that 119 “care and service delivery problems” by NHS services, especially TEWV, had occurred. Charlotte and Michael Harnett, Christie’s parents, said their daughter had “lost her life whilst in a hospital run by TEWV trust where there was little or no care or compassion”. Emily’s parents, David and Susan Moore, said she received “horrific care” while at West Lane. Services at the hospital were understaffed, “unstable and overstretched”, the investigation’s final report found. Both families, and also Nadia’s parents, Hakeel and Arshad Sharif, said the dangerous inadequacy of the care provided by TEWV, and the likelihood that other patients with fragile mental health had died as a result, showed that ministers should order a full public inquiry. “This mental health trust is a danger to the public,” the Moores said. The report said TEWV failed to properly monitor the girls, given their known risk of self-harm; to take seriously concerns about their care and suicide risk raised by their families; and to remove all potential ligature points. Read full story Source: The Guardian, 2 November 2022
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