Jump to content
 View Profile  See their activity

  • Posts

    11,697

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

Everything posted by Patient Safety Learning

  1. 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.
  2. 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
  3. 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.
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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.
  10. 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.
  11. Content Article Comment
    @Aoife McCarthy Hi. The link should now work.
  12. 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.
  13. 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.
  14. 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.
  15. 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
  16. 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
  17. 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.
  18. 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.
  19. 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.
  20. 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
  21. 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
  22. 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.
  23. 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
  24. 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.
  25. 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.
×
×
  • Create New...