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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Two and a half years after Boris Johnson announced the first UK lockdown, and seven months after the last domestic measures ended, some care homes in Britain are still denying people access to their elderly relatives due to Covid restrictions. Grandchildren have been banned by some homes, which put age limits on visitors. Others exclude whole families except for one relative named as “essential caregiver”, something that was dropped from government guidance in April. Support groups the Relatives & Residents Association (R&RA), and Rights for Residents also said there were homes not allowing people to see their parents, husbands or wives in their rooms, instead insisting that the visits take place in pods outside. And some only allow limited timed-visiting slots. About 70% of older care home residents have dementia and often find it distressing to be moved, only settling by the end of the slot. Campaigners have been calling for action to protect care home residents since the first lockdown, because relatives are often best able to help. Research from John’s Campaign shows that people who know someone with dementia are much better at interpreting their behaviour and giving comfort. Read full story Source: The Guardian, 25 September 2022 You may also be interested to read these two original blogs posted on the hub: Visiting restrictions and the impact on patients and their families: a relative's perspective It’s time to rename the ‘visitor’: reflections from a relative
  2. News Article
    Staff at the Care Quality Commission (CQC) have been left ‘in fear of speaking out’ against structural changes to the organisation which they believe ‘pose a significant risk’ to the CQC’s ability to regulate health services, trade unions have told the health and social care secretary. A letter signed by senior officers of Unison, Royal College of Nursing, Unite, Prospect and the Public and Commercial Services union has called on Therese Coffey to urge the CQC to pause its organisational change and enter into “meaningful discussions” with the unions. The unions have raised concerns that organisational changes to the CQC have been drawn up by consultants with no frontline experience in health and social care, or in regulation, and that staff have had limited input into the changes. They allege that staff raising concerns about the changes have been dismissed as being “disruptive” or “negative”, and significant numbers of experienced staff have recently left the regulator. The CQC said in response to the letter that the changes it was proposing were needed to enable the regulator to “work more effectively across the health and care system”, and that it has engaged with trade unions throughout the process. Read full story (paywalled) Source: HSJ. 23 September 2022
  3. News Article
    Up to 600 patients are to be recalled by a hospital after concerns were raised about shoulder operations. Some patients have lost the use of their arm after surgery by Mian Munawar Shah at Walsall Manor Hospital. Angela Glover had two operations by Mr Shah - the first, it later emerged after a review, was unnecessary and a screw had been placed inappropriately. Her partner Simon Roberts said she was in "constant pain" and was unable to raise her arm or grip things in her right hand. It has affected her mental health to the point she had to be sectioned after a suicide attempt, Mr Roberts added. Mr Martin Crowley had an operation in 2019 after dislocating his shoulder - Mr Shah then replaced the joint when the first operation was unsuccessful. Since then, he said he struggled with basic tasks such as buttoning up a shirt or holding a cup of tea. "It's affecting me quite bad, there's a lot of stuff I want to do that I can't do," he said. Between 2010 and 2018 there were 21 medical negligence claims relating to Mr Shah's surgery. In 2020, Walsall Healthcare Trust contacted the Royal College of Surgeons (RCS) which carried out a general review of surgery and then a further review into Mr Shah's individual work. A recall of his patients was recommended by the RCS. The surgeon has been given an interim order by the Medical Practitioners Tribunal Service (MPTS), stopping him from doing laterjet procedures or shoulder joint replacements without supervision. Medical director at the Walsall trust Dr Manjeet Shehmar told the BBC there had been a failure to carry out multi-disciplinary team meetings and some of the procedures should have been performed in a specialist orthopaedic hospital rather than at Walsall Manor. Read full story Source: BBC News, 26 September 2022
  4. Content Article
    An open letter to Brandon Lewis, the justice secretary, and the Sentencing Council for England and Wales warns that pregnant women in jail suffer severe stress and highlights evidence suggesting they are more likely to have a stillbirth. The signatories include the Royal College of Midwives and Liberty.
  5. News Article
    The Deputy President of the Medical and Health Workers Union of Nigeria, Kabiru Sani, has said that 50% of deaths recorded in the sector are caused by unsafe medication practices and medication errors. This is as he lamented that the health sector loses $42bn annually due to the wrong medications. He stated this at an event in commemoration of 2022 World Patient Safety Day, themed, “Medication Safety” held in Abuja. He said, “According to WHO, unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. Globally, the cost associated with medication errors has been estimated at $42bn annually. “We, therefore, need to draw the domestic and global attention of all relevant authorities to the challenges facing patients, and healthcare workers and the urgent need to ameliorate them. The overall objective of world patient safety is to enhance and promote global understanding of patient safety, increase public engagement in the safety of healthcare workers, and promote global actions to enhance patient safety and reduce patient harm." Read full story Source: Punch, 20 September 2022
  6. Content Article
    In this article in the Patient Safety Journal, Mayher Profita, a third-year surgical resident in Pennsylvania, describers her residency and the burnout she experienced. "The burnout was making us care less about our patients and the care they received and more about whether we made the right career choice."
  7. News Article
    In order to avoid risk of having adverse drug reactions capable of prolonging the treatment period in the health facilities in Nigeria, experts have advocated the empowerment of patients to know the drugs being administered on them. The call was made when the Occupational Health and Safety Managers in Nigeria commemorated the Work Patient Safety Day with the National Orthopaedic Hospital Igbobi, NOHI, Speaking at the programme aimed to advocate patient safety to members of staff of the NOHI with the theme: Medication Safety with the slogan ‘MEDICATION WITHOUT HARM’, the Director of Nursing services, NOHI, Mrs Temidayo Rasaq-Oyetola, said where there is no medication safety, patient is at the risk of having adverse reaction that can prolong his or her treatment period. She said: “Patients have the right to know their drugs and seek for clarification when necessary. “Where there is no medication safety, patient is at risk of having adverse reaction that can prolong the treatment period. “Patient’s safety should be every stakeholder’s priority that will lead to delivery of efficient health care and best patient outcome. Also, every health institution should ensure medication safety with series of checks.” Read full story Source: Vanguard, 23 September 2022
  8. Content Article
    Specialised services typically care for small numbers of patients with rare or complex conditions. They are commonly overlooked in debates around the future of the NHS. This is despite costs growing by over 50% in eight years, and now exceeding £20bn per year. The spotlight is returning, with proposals from NHS England to change how these services are planned, with power and responsibility being devolved down to new Integrated Care Boards – sub-regional structures across England. This report sets out a series of recommendations which Policy Exchange believe should underpin these reforms, including refinement of the services into more logical groupings, an expanded role for patient and carer input into service design, and stronger ministerial and financial oversight to ensure the sustainability of service delivery for the longer term.
  9. Content Article
    Vonda Vaden Bates is an alliance builder and leadership coach. For over 30 years Vonda has guided professionals to succeed on behalf of their organisations and careers. She helps people move from potential to action, set and reach goals, manage engaged teams, and communicate with influence. In 2013 Vonda decided to contribute her skills on behalf of safety in healthcare after researching how her husband, Yogiraj Charles Bates, died from one of the most common preventable causes of death, hospital-associated venous thromboembolism. Advocating for every person in the care system, Vonda brings a compassionate voice, strategic skills, and collaboration expertise to improve communication and safety in healthcare. The Patient Safety Movement share her story.
  10. News Article
    NHS England has this week told trusts it is abandoning a patient safety target ‘until maternity services in England can demonstrate sufficient staffing levels’ to meet it. The Midwifery Continuity of Care model was designed to ensure expectant mothers would be cared for by the same small team of midwives throughout their pregnancy, labour and postnatal care. It was a key recommendation of 2016’s Better Births review of English midwifery services. NHSE’s chief midwifery officer for England Jacqueline Dunkley-Bent championed the policy and guidance on its implementation was issued in October. However, in her report on the care failures at Shrewsbury and Telford Hospital Trust’s maternity department, Donna Ockenden said the Midwifery Continuity of Care model should be suspended until more evidence was gathered about its effectiveness and there were enough midwives to meet minimum staffing requirements. Ms Ockenden said patient safety had been “compromised by the unprecedented pressures that Continuity of Care models of care place on maternity services already under significant strain”. Read full story (paywalled) Source: HSJ, 23 September 2022
  11. Content Article
    Repeated culture of safety surveys of the nursing staff at Children’s Hospital of Philadelphia’s main campus demonstrated lagging scores in the domain of nonpunitive responses to error. The hospital had tried for many years to address the problem using a variety of strategies, including small group training sessions on just culture for staff and leaders, but had met with limited success. Finally, in 2015, it committed to trying something genuinely different—even perhaps disruptive—that might actually shift the stagnant metrics. Their novel, multifaceted programme, implemented over a two-year period, yielded a 13% increase in staff rating scores that the hospital has been able to sustain over the subsequent two-year period.  The design and rollout of our program was neither simple nor smooth, but valuable lessons were learned about realistic, operational implementation of principles of psychological safety in a large and complex clinical organisation. In this paper, Neiswender et al. describe the programme and the lessons learned in the journey from idea inception to post-implementation.
  12. News Article
    Tinkering around the edges, the King's Fund said. A few short-term fixes, according to the Health Foundation. And a plan that will have minimal impact, the Royal College of GPs added. These were just a handful of the reactions from those involved with the NHS. And they were not even from organisations usually at the front of the queue when it comes to criticising government policies. So why has Therese Coffey's first announcement as Health Secretary for England received such a negative response? The fact is the problems the health and care system are facing are deep-rooted. Much is made of the impact of the pandemic but the health service was already struggling before Covid hit. The pandemic has simply exacerbated the situation. At the heart of it all is a lack of staff. Addressing this is not easy and cannot be done overnight. It takes five years to train a doctor, three a nurse, which is why there is a big push on international recruitment at the moment. To free up GP appointments, pharmacists are being asked to take on some of their workload, while funding rules are being relaxed to allow GPs to use more of their money to recruit senior nurses. But there is nothing in the plan about where these new senior nurses are going to come from, which is why the Royal College of GPs has been so dismissive. It is a similar story for hospitals services, where accident-and-emergency waits, ambulance response times and the backlog in routine treatments such as knee and hip replacements have all worsened in recent years. Coffey is also introducing a £500m fund to get thousands of medically fit patients out of hospital as soon as possible. Local areas will decide how to spend the money and it could allow hospitals to pay for extra help at home for patients who need it. But it amounts to little more than a sticking plaster and is an approach already used to relieve the pressure during the pandemic. The real issue is the care sector is short of staff, with even more vacancies than in the NHS. Read full story Source: BBC News, 22 September 2022
  13. Content Article
    Therese Coffey, the new health and social care secretary, sets out the government’s plans for the NHS and social care to deliver for patients, this winter and next. The government's plan for patients sets out the priorities for health and care, delivering across four key areas: ambulances backlogs care doctors and dentists. Read her Ministerial foreword below.
  14. News Article
    Several patients awaiting treatment on the Welsh NHS have turned to surgery abroad as waiting lists hit record levels again. Waiting lists hit a record of almost 750,000 in July prompting surgeons to demand "urgent action". The Welsh government said waits of more than two years were improving. Health Minister Eluned Morgan said there were "signs of hope" that a target for no-one to wait more than a year for their first outpatient appointment could be hit by the end of 2022. But the Conservatives accused Labour ministers of having "little strategy" to tackle "extraordinary waits", while Plaid Cymru called for action "to increase capacity and improve patient flow". Sharon Seymour, 62, from Monmouthshire, went to Lithuania after being told she faced a "two years plus" wait for a hip replacement. The council worker said she also found out about Lithuania from other patients in Wales and had her surgery in July. She said the fact that people were taking matters into their own hands suggested the health system in Wales was not working. "[The NHS] does need a huge cash injection... a rethink completely now," she said. "The sadder point is the people who have the ability to pay will get it. "The inequality between those who can't and that [can is] a sad state of affairs," she added. "It's only through luck that we've managed to find the funds to go to Lithuania. "For most people, it isn't an option and that's horrible." Read full story Source: BBC News, 22 September 2022
  15. News Article
    Sickle cell patients’ experiences of barriers to treatment and racial inequalities will be investigated by an NHS body next month, The Independent has learned. The NHS Race and Health Observatory has collaborated with Public Digital, a consultancy group, to lead original research into the experiences of people with sickle cell, including listening to NHS patients’ and carers’ first-hand accounts of acute emergency hospital admissions and managing the condition at home. Research will focus on a series of interviews and ‘experience mapping’ workshops, the findings of which are anticipated to inform recommendations that will help improve emergency care and treatment pathways. “As a priority, we need to discover new measures and treatment plans that can help eradicate the often unacceptable, substandard care people with sickle cell have historically received whilst being unwell and in acute pain,” Dr Habib Naqvi, Director of the NHS Race and Health Observatory, said. This move comes after a parliamentary inquiry into avoidable sickle cell deaths called upon the Observatory to undertake work into sickle cell care in relation to race and ethnicity. The inquiry published a report, ‘No one’s listening’, in November 2021, which uncovered the bleak reality of patients grappling with racism in the NHS while attempting to access healthcare. Only half of healthcare professionals feel they have sufficient tools to manage the long-term damage that sickle cell disease brings, new research from Global Blood Therapeutics found, following extensive studies carried out across 10 countries including the UK, US and Canada. Read full story Source: The Independent, 22 September 2022
  16. News Article
    An integrated care system which has some of England’s worst waiting times for emergency care lacks “delivery structure and processes” to make desperately needed improvements, according to an external report. Research by consultancy Prism into the Cornwall and Isles of Scilly integrated care system (ICS) concluded it had “unclear governance” for management and recovery of urgent and emergency care, with “multiple disconnected structures in place to manage tactical and strategic recovery of performance”. The report comes as the ICS grapples with record waits for emergency care, with stroke and heart attack victims waiting three hours for an ambulance and patients stuck for two days in Royal Cornwall Hospital’s emergency department. The review was commissioned by the Cornwall Integrated Care Board to look at patient flow across the system and make recommendations about how this can be improved. Prism interviewed leaders from the organisations within the Cornish ICS. One leader described the system as “so broken”, while another commented that the role of the ICB in supporting and delivering urgent and emergency care “is not clear”.
  17. Content Article
    Risk managers and the insurers with whom we work have the greatest opportunity in healthcare today to improve patient safety. Our most egregious mistakes become medical malpractice claims and lawsuits. Some of these go to trial where the outcome is public; however, the least defensible cases are settled without a trial. Almost every settlement includes a confidentiality or nondisclosure clause (NDC). Such clauses become “gag orders.” Providers who could learn from the mistake of a colleague do not, and the same mistake is repeated, often many times over. The stories of these settlements are a rich source of learning, and it’s time to tell them—anonymously. No naming names, no disclosure of settlement amounts, no “blame and shame.” Stories are powerful, attention-grabbing, and memorable. Telling them is a unique opportunity to link the prevention of patient harm to the healing mission of healthcare and acknowledge the common wish of every plaintiff that “this won’t happen to someone else.”
  18. News Article
    Therese Coffey has pledged there will be no changes to the four-hour target for A&E waiting times – despite NHS England’s prolonged bid to axe the controversial measure. The new health and social care secretary told the House of Commons Thursday: “I can absolutely say there will be no changes to the target for four-hour waits in A&E.” Ms Coffey’s comments appear to represent a major blow to NHS England, which has since 2019 been pushing for a new bundle of metrics to replace the target. Fourteen trusts have been trialling these, which include measures such as average time spent in an emergency department and 12-hour waits from time of arrival, as part of the Clinical Review of Standards. NHSE had also, after a protracted battle, secured the support of key stakeholders, including the Royal College of Emergency Medicine, NHS Providers and Heathwatch England, to back its plans to ditch the target, for so long the NHS’s most significant performance metric. The bold position – with Ms Coffey just weeks into the role – also contradicts the stance taken by both recent predecessors Sajid Javid and Matt Hancock, who both signalled they were supportive of scrapping the target. Read full story (paywalled) Source: HSJ, 22 September 2022
  19. News Article
    Ministers are setting up a £500m emergency fund to get thousands of medically fit patients out of hospital as soon as possible in an attempt to prevent the NHS becoming overwhelmed this winter. Thérèse Coffey, the new health secretary, unveiled the move in the Commons on Thursday as part of her plans to tackle the growing crisis in the health service, especially patients’ long delays for care. The newly created adult social care discharge fund is intended to relieve the pressure on overstretched hospitals in England by ensuring that patients whom doctors have judged well enough to leave can be safely discharged either to their home or into a care home. In her first speech since becoming the health secretary 16 days ago, Coffey told MPs: “I can announce today that we are launching a £500m adult social care discharge fund for this winter. “The local NHS will be working with councils with targeted plans on specific care packages to support people being either in their own home or in the wider community. This £500m acts as the downpayment in the rebalancing of funding across health and social care as we develop our longer-term plan.” Read full story Source: The Guardian, 22 September 2022
  20. Content Article
    An estimated 1 in every 182 Americans will be diagnosed with cancer this year. Providing them safe care has inherent challenges, such as reaching an accurate diagnosis as quickly as possible, differentiating between disease progression and treatment side effects, and addressing broader systemic risks. Caitlyn Allen, sat down with medical oncologist and former chief quality officer of the Dana-Farber Cancer Institute, Dr. Joseph O. Jacobson, to discuss the evolution of oncology care and what the future may hold.
  21. Content Article
    The UK health system is under unprecedented strain. The COVID-19 pandemic exacerbated these pressures, but it did not create them. The Academy of Medical Royal Colleges and its member organisations believe that as a country we are not facing up to the scale of the current challenges and we are not producing any coherent strategy to tackle the problems. Only when we confront these challenges will we be able to begin to fix the NHS. A combination of pressures means that the system is providing care and services which are sub-standard, threaten patient safety and fall below what should be expected in a country with the resources of the United Kingdom. If we do not act with urgency, we risk permanently normalising the unacceptable standards we now witness daily, to the detriment of us all.
  22. News Article
    A special House panel investigating America's response to the coronavirus pandemic said it has found anecdotal evidence of understaffing at nursing homes that led to patient neglect and harm. At a hearing Wednesday, the select subcommittee on the coronavirus crisis plans to discuss some of its findings, including how large nursing home chains reacted to complaints from staff and families. “Many nursing home facilities were severely understaffed during the early months of the pandemic, leading to deficient care, neglect, and negative health outcomes for residents,” the committee reported Wednesday in a news release in advance of the hearing. President Biden earlier this year instructed the Centers for Medicare and Medicaid Services [CMS] to develop minimum staffing standards for nursing homes. By highlighting problems during the pandemic, the House hearing on Wednesday increases pressure on nursing homes and the Biden administration as that work by CMS continues. The agency said recently it plans to study staffing levels through the winter. Read full story (paywalled) Source: The Washington Post, 21 September 2022
  23. News Article
    Protesters took to the pavement outside the White House on 19 September to demand a better deal for people affected by Long Covid, complaining that the Biden administration’s plans fell short on action and funding. “The pandemic is over,” President Joe Biden declared the night before in a pre-recorded interview which aired on the news magazine 60 Minutes. “We still have a problem with covid,” he said. “We’re still doing a lot of work on it but the pandemic is over. If you notice, no one’s wearing masks. Everybody seems to be in pretty good shape. And, so, I think it’s changing.” But the scene outside the presidential mansion the next day belied that message. Wearing black masks and red shirts, protesters called for research, medical treatment, and social services for those with Long Covid. Around half would qualify for a diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome. The protest was organised by #MEAction, an international network of patient advocates. “I went undiagnosed for 15 years, because doctors are not educated about the condition,” Jennifer Nish told The BMJ. Nish, from Lubbock, Texas, said that she was inspired to help organise the protest to raise awareness. “I don’t want anyone to go through what I had to go through,” she said and called on “the White House to treat this like the emergency that it is.” Read full story Source: BMJ, 20 September 2022
  24. Content Article
    The UK’s new health secretary, Thérèse Coffey, has not taken on an easy job. Almost two-thirds of trainee GPs plan to work part-time just a year after they qualify, reporting that the job has become too intense to safely work more. A record 6.8 million people are waiting for hospital treatment in England, and 132,139 posts lie vacant across the NHS in England. Ian Sample hears from acute medicine consultant Dr Tim Cooksley about what’s happening within the NHS, and speaks to the Guardian’s health policy editor, Denis Campbell, about how the UK’s health and social care systems ended up in crisis and whether they can be fixed.
  25. Content Article
    Duplicate medication orders are a prominent type of medication error that in some circumstances has increased after implementation of health information technology. Duplicate medication orders are commonly defined as two or more active orders for the same medication or medications within the same therapeutic class. While there have been several studies that have identified contributing factors and described potential solutions, duplicate medication order errors continue to impact patient safety.
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