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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Only 1 in 3 people were fully recovered from COVID-19 a year after they left hospital. Being female, having obesity or being on a ventilator were each linked with ongoing symptoms, months after people were discharged (Long-COVID). Nearly 1 million people in the UK have so far been admitted to hospital because of COVID-19. The long-term effects of the infection in this group are only just coming to light. Researchers explored the impact of being hospitalised for COVID-19 on people’s mental and physical health, and on their employment. They looked at characteristics such as age and sex to see which were associated with worse recovery. They also assessed whether inflammation in the blood may be a potential target for treatment. This study described, for the first time, four different patterns of COVID-19 recovery. It found, for example, that some people with long-COVID had higher levels of inflammation. The researchers say that targeting treatment to specific clinical problems, such as treating inflammation in people with higher levels of inflammation, are promising approaches to aid recovery.
  2. Content Article
    The purposes of the Canadian Medication Incident Reporting and Prevention System (CMIRPS) programme are to:Coordinate the capture, analysis and dissemination of information on medication incidents;Enhance the safety of the medication use system for Canadians.Support the effective use of resources through the reduction of potential or actual harm caused by preventable medication incidents.The goals of the CMIRPS information system are to:Collect data on medication incidents.Facilitate the implementation of reporting of medication incidents.Facilitate the development and dissemination of timely, targeted information designed to reduce the risk of medication incidents (e.g. ISMP Canada Safety Bulletins).Facilitate the development and dissemination of information on best practices in safe medication use systems.
  3. Content Article
    This guide is designed to support healthcare providers when talking to patients about the use of of oxytocin to start or advance labour.
  4. News Article
    Patients seeking treatment for mental health problems at hospital emergency departments in England were twice as likely to experience "unacceptable" waiting times of 12 hours or more than other patients, according to a service review. The Royal College of Emergency Medicine (RCEM) described its findings as "unacceptable" and said the system frequently failed who were most unwell and vulnerable, particularly children and young people. The report, Mental Health and Emergency Care, is the latest in the RCEM's acute insight series summarising important issues in emergency care and making recommendations for policymakers, NHS England, integrated care systems, and trusts. The analysis noted that recorded prevalence of patients experiencing mental health needs had "dramatically increased" over the last 5 years. Despite accounting for a small proportion of attendances to emergency departments (EDs), a "mismatch" between capacity and demand, cuts to dedicated mental health hospital beds, and poor patient flow through the hospital system had led to long waits in recent months. The greatest concern was for patients waiting for a mental health bed, those waiting for assessment under the Mental Health Act, and children and young people presenting in crisis, the RCEM said. Read full story Source: Medscape, 22 September 2022
  5. Content Article
    This instalment of Royal College of Emergency Medicine (RCEM)’s Acute Insight Series summarises key issues in mental health emergency care and provides recommendations for policymakers, NHS England, Integrated Care Systems, and Trusts to enable patients to access emergency mental healthcare in a safe, efficient, and timely manner.
  6. News Article
    One in four people could be left without a GP within a decade, medics say. The forecasts from Doctors’ Association UK suggest 16 million people in England could be left without access to a family doctor, amid growing staffing shortages. Today the new Health Secretary is expected to set out plans to boost access to GPs, following warnings that public satisfaction is the lowest on record. Research by the Health Foundation suggests that the NHS will lose up to 8,800 full-time equivalent GPs by 2030 if current trends continue. On Wednesday, Doctors’ Association UK said this could leave one in four people without access to a GP. Dr Lizzie Toberty, GP lead for the Doctors’ Association UK, said the workload of a family doctor now placed “unrealistic demands” on them. She said: “GPs will cut their hours, quit the NHS, or quit the country. We fear patients will suffer the same ‘postcode lottery’ for seeing their GP as many do now with getting an NHS dentist.” Read full story (paywalled) Source: The Telegraph, 21 September 2022
  7. News Article
    The Care Quality Commission (CQC) has urged system leaders to move away from “quick fixes” to the “enormous gap in resources and capacity” in urgent and emergency care. A report by the CQC and a large group of emergency clinicians and other health and care leaders calls for a ”move away from reactive ‘quick fixes’ such as tents in the car park or corridor care to proactive long-term solutions and to address the enormous gap in resources and capacity”. The use of tents and treating more patients in corridors have been increasingly adopted by hospitals in recent months, sometimes encouraged by NHS England, particularly when they are under pressure to reduce handover delays from ambulances. The report, 'People First: a response from health and care leaders to the urgent and emergency care system crisis', suggests: expanding use of urgent community response teams to attend minor injuries 999/111 calls, giving acute and social care providers direct access to GP and community service booking systems, and providing “rapid access” to support packages to help people avoid hospital admission. Read full story (paywalled) Source: HSJ, 22 September 2022
  8. News Article
    A private hospital has been rated ‘inadequate’ by a health watchdog following an inspection prompted by a young patient’s preventable death. Woodbourne Priory Hospital, in Edgbaston, has had its overall Care Quality Commission rating downgraded from “good” to “inadequate” after inspectors visited in May. The regulator’s visit was sparked by a prevention of future deaths report into the death of Birmingham University graduate Matthew Caseby, 23, who was placed at the hospital as an NHS-funded patient in September 2020. Mr Caseby had been detained under the Mental Health Act but managed to escape Woodbourne and died after being struck by a train. Earlier this year, an inquest concluded his death was contributed to by neglect on behalf of the hospital. In April, Birmingham and Solihull coroner Louise Hunt flagged urgent concerns about record keeping, risk assessments and security of courtyard fences with Priory Group and the Department of Health and Social Care. Read full story (paywalled) Source: HSJ, 22 September 2022
  9. News Article
    The government is promising to improve access to GPs, including same-day appointments for those that need them, as part of a new plan in England. Health Secretary Thérèse Coffey will make the pledge as she unveils her NHS plan for this winter and next. GPs will be able to take on extra staff, including senior nurses, while pharmacists will be asked to take on more work to free up appointments. Ms Coffey is due to announce the plan, which will also cover hospital services, in the House of Commons today. She is expected to say: "I will put a laser-like focus on the needs of patients, making their priorities my priorities and being a champion for them on issues that affect them most." Alongside same-day appointments when needed, Ms Coffey will promise no-one will have to wait more than two weeks for a routine appointment - currently one in five appointments take longer. The promises on waiting times are not official targets, but Ms Coffey said they should be seen as clear expectations of what patients should be entitled to. But GP leaders said the announcement would have a "minimal impact". Read full story Source: BBC News, 22 September 2022
  10. Content Article
    70,000 people in the UK are living with pulmonary fibrosis. Action for Pulmonary Fibrosis has the information, support and stories to help you live a healthier life with pulmonary fibrosis.
  11. Content Article
    “I wish my GP had known more about my disease” is a comment made by patients with pulmonary fibrosis and idiopathic pulmonary fibrosis on a regular basis. Pulmonary fibrosis can be difficult to diagnose and misdiagnosis is common. That’s why Action for Pulmonary Fibrosis has partnered with the Royal College of General Practitioners to create a new module aimed at improving awareness of pulmonary fibrosis diagnosis. They have also got resources and materials for your patient, so that they have the support they need from diagnosis.
  12. Content Article
    From April 2023 the new Health Services Safety Investigations Body will require doctors to be candid about errors that have led to patient harm. But can medics trust that material given in this “safe space” won’t be used against them?
  13. News Article
    No patient data held by mental health trusts was taken following a cyber attack this summer, NHS England has confirmed. The regulator told HSJ it had received confirmation from tech firm Advanced, which was the subject of a cyber attack in July, that no data had been breached on its Carenotes electronic patient record. The EPR is used by around a dozen mental health trusts. The process of reconnecting trusts fully back to Carenotes also started this week, after providers spent two months with limited or no access to their EPR. HSJ previously revealed that senior NHS chiefs feared patient data may have been taken or accessed by those responsible for the cyber attack, who issued ransom demands to Advanced. Since then, experts have been brought in to investigate any potential data impact following the attack. Read full story (paywalled) Source: HSJ, 21 September 2022
  14. Content Article
    PEOPLE FIRST is a CQC resource to help system leaders and service providers.
  15. News Article
    Women in the UK with type 2 diabetes have a 60% increased risk of an early death and will live five years less than the average woman in the general population, early research suggests. Scientists have also found that men with the disease have a 44% increased risk of dying prematurely and live 4.5 years less. Results also suggest that smoking shortens the life expectancy of people with type 2 diabetes by 10 years, while diagnosis at a younger age cuts life expectancy by over eight years. The findings, presented at the European Association for the Study of Diabetes in Stockholm, Sweden, are based on a cohort of nearly 12,000 patients at the Salford Royal Hospital in Salford. “A woman with type 2 diabetes, for example, might live five years less than the average woman in the general population, while someone diagnosed at a younger age might lose eight years of life expectancy. “It is vital that the groups at the highest risk are made aware of not just the increased risk that they face but also the size of the risk." “Doing so may make the health advice they are given seem more relevant and so help them make changes that can improve their quality – and length – of life.” Read full story Source: The Independent, 21 September 2022
  16. News Article
    For the first time, a US government-backed expert panel has recommended that adults under 65 should be screened for anxiety disorders. The influential US Preventive Services Task force also said that all adults should be checked for depression, consistent with past guidance. The change follows widespread warnings from experts on the mental health toll of the Covid-19 pandemic. The task force stopped short of a screening recommendation for suicide. The panel acknowledged that suicide is a leading cause of death among American adults but said there was "not enough evidence on whether screening people without signs or symptoms will ultimately help prevent suicide". The draft guidance is aimed at young and middle-aged adults, including those who are pregnant and post-partum. It envisions the mental health screening as part of routine visits with primary care physicians, said Dr Lori Pbert, a task-force member and professor in the Department of Population and Quantitative Health Sciences at UMass Chan Medical School. "When you go to your primary care provider, you get screened for many, many preventive conditions - blood pressure, heart rate, all kinds of things," she said. "Mental health conditions are just important as other physical conditions, and we really need to be treating mental health conditions with the same urgency that we do other conditions." Read full story Source: BBC News, 20 September 2022
  17. News Article
    Adult social care in England is in serious crisis, Tory council leaders have warned the government, as it faces a £3.7bn funding gap and a growing staffing shortage that has brought many local care providers to the brink of collapse. The intervention by the County Councils Network, which represents 36 mainly Tory-run authorities, comes amid widespread local government concern over the increasing fragile state of social care. Care costs have accelerated recently, fuelled by unexpected wage and energy inflation. “We face the perfect storm of staffing shortages, fewer care beds, and higher costs – all of which will impact on individuals waiting for care and discharges from hospital,” said Martin Tett, the Tory leader of Buckinghamshire county council. Cathie Williams, the chief executive of the Association of Directors of Adult Social Services, said: “Too many people are missing out on vital care and support – we estimate that over half a million people are waiting for assessments, care, or reviews. With over 165,000 staff vacancies, this is only set to get worse. ” A government spokesperson said: “The health and social care secretary is focused on delivering for patients and has set out her four priorities of A, B, C, D – reducing ambulance delays, busting the Covid backlogs, improving care, and increasing the number of doctors and dentists. Read full story Source: The Guardian, 21 September 2022
  18. News Article
    A leading academic is calling on new Health Secretary Therese Coffey to reconsider rolling out a Covid drug for people with weakened immune systems. Last month the government decided it would not supply Evusheld in the UK. But Dr Lennard Lee, an academic medical oncologist from Oxford University who is backed by more than 120 leading scientists and clinicians, said a rethink was needed. The government said more data was required on the treatment. Evusheld was approved for use in March, but was reviewed after the Omicron variant emerged. The drug's manufacturer AstraZeneca said there was "ample real-world data" that it worked. It is currently available in 32 countries. Dr Lee told the BBC: "It's time for a re-review of the data, and to think about transparency in terms of why they decided not to do this, and also the pros and cons of doing this. "We do know that coronavirus cases are likely to go up in winter, and we do know there are people who face increased risks... "Therefore if there is anything we can do to protect... anyone immunosuppressed I think this is something that does need to be reconsidered." Research from the US and Israel suggests Evusheld reduces the risk of infection by about 50%, and cuts the risk of serious illness by 90%. Read full story Source: BBC News, 21 September 2022
  19. News Article
    The most common reasons why people with type 2 diabetes (T2DM) are admitted to hospital with greater frequency than the general population are changing, with hospitalisation for traditional diabetes complications now being accompanied by admissions for a diverse range of lesser-known complications including infections (i.e., pneumonia, sepsis), mental health disorders, and gastrointestinal conditions, according to an analysis of national data from Australia spanning seven years. The findings, being presented at this year's European Association for the Study of Diabetes (EASD) Annual Meeting in Stockholm, Sweden (19-23 Sept), reveal that just four traditional diabetes complications (cellulitis, heart failure, urinary tract infections, and skin abscesses) were ranked in the top ten leading causes of hospitalisation in men and women with T2DM. "Although traditional complications such as heart failure and cellulitis remain a substantial burden for people with T2DM, infections less commonly linked with diabetes and mental health disorders are emerging as leading causes of hospital admissions, and have substantial burdens that sometimes exceed the top-ranked well-known complications," says lead author Dr. Dee Tomic from the Baker Heart and Diabetes Institute, Melbourne, Australia. She adds, "The emergence of non-traditional diabetes complications reflects improvements in diabetes management and people with diabetes living longer, making them susceptible to a broader range of complications. Increasing hospitalizations for mental health disorders as well as infections like sepsis and pneumonia will place extra burden on healthcare systems and may need to be reflected in changes to diabetes management to better prevent and treat these conditions." Read full story Source: MedicalXpress, 1 September 2022
  20. Content Article
    Not knowing how to unfold or even sit in a wheelchair the right way can cause a catastrophic injury to patients, visitors, volunteers, and staff of a healthcare facility. Wheelchairs are one of the most common assistive devices used in healthcare facilities, from admission to discharge. They are often found at the entrance of a facility for use by both patients and visitors with mobility issues. Hospital volunteers, transport staff, and clinical staff use wheelchairs to take patients to different care areas to have tests performed. Many facilities require that patients be transported in a wheelchair upon discharge. However, not knowing the proper method of unfolding a wheelchair or where to place your hands when sitting down in the seat can cause injuries, specifically to fingers, ranging from lacerations to amputations.
  21. Content Article
    Serious incident (SI) investigations aim to identify factors that caused or could have caused serious patient harm. This study from Mary Dixon-Woods and colleagues aimed to use the Human Factors Analysis Classification System (HFACS) to characterise the contributory factors identified in SI investigation reports.
  22. Content Article
    Diagnostic errors are major contributors to patient harm. Strategies to identify and analyse these events are still emerging, but several show promise for use in operational settings. The Agency for Healthcare Research and Quality (QHRQ) has developed Measure Dx to help healthcare organisations identify diagnostic safety events and gain insights for improvement. Measure Dx can be used by any healthcare organisation interested in promoting diagnostic excellence and reducing harm from diagnostic safety events. Potential users include clinicians, quality and safety professionals, risk management professionals, health system leaders, and clinical managers.
  23. Content Article
    A digital transformation is underway in healthcare and health technology. But what exactly do the smart hospitals of the future look like? Are we heading for a fully virtual health experience? Whether it’s AI and machine learning, or another form of innovation – it’s clear to see that health tech, and healthcare, is changing drastically. The words “smart hospital” and “virtual hospital wards” have eased their way into our vocabulary – and they will soon be the driving force of healthcare everywhere. So what would smart hospitals look like? And what should we be expecting between now and 2050? Health Tech World asked some of the leading experts in the field to give us their predictions as well as their expertise on what the healthcare of the next few decades will look like.
  24. Content Article
    Women are 50% more likely to receive a wrong initial diagnosis; when they are having a heart attack, such mistakes can be fatal. People who are initially misdiagnosed have a 70% higher risk of dying. The latest studies have similarly shown that women have worse outcomes for heart operations such as valve replacements and peripheral revascularisation. As well as being misdiagnosed, women are less likely to be treated quickly, less likely to get the best surgical treatment and less likely to be discharged with the optimum set of drugs. None of this is excusable, but is it understandable? What is behind this bias and how can how it be fixed? Sian Harding, emeritus professor of cardiac pharmacology at Imperial College London, looks at the evidence in this Guardian article. Related reading Dangerous exclusions: The risk to patient safety of sex and gender bias Gender bias: A threat to women’s health Medicines, research and female hormones: a dangerous knowledge gap
  25. News Article
    Performance on waiting times targets at Scotland's hospital A&E units has hit a new low. Figures for the week ending 11 September showed just 63.5% of patients were dealt with within four hours. Health Secretary Humza Yousaf said the figures were "not acceptable" and he was determined to improve performance. Scottish Tory health spokesman Dr Sandesh Gulhane said the figures showed the "crisis in A&E is not merely continuing, but deepening". The Scottish government target is that 95% of patients attending A&E are seen and subsequently admitted or discharged within four hours. Doctors working in emergency medicine have issued stark warnings recently about the impact of long waits in A&E. It is simply not safe, and patients are dying as a result, they say. Read full story Source: BBC News, 20 September 2022
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