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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Millions of people in the UK are suffering poor health because they miss out on vital rehabilitation after strokes, heart attacks and cancer, which in turn is also heaping further pressure on the NHS, a damning report warns. Physiotherapists say some groups of patients are particularly badly affected. Without access to these services, many patients desperately trying to recover from illness became “stuck in a downward spiral”, they said, with some developing other health conditions as a result. The new report by the Chartered Society of Physiotherapy (CSP) says millions of people in marginalised communities, including those from ethnic minorities, are not only more likely to live shorter lives, but also spend a greater proportion of their lives struggling with health difficulties. Vital services that could tackle those inequities are either unavailable or poorly equipped to meet their needs, the report warns, adding that “some communities face particular barriers”. Prof Karen Middleton, the chief executive of the CSP, said: “Rehabilitation services have been under-resourced for decades and were not designed coherently in the first place. This has exacerbated poor health outcomes, particularly for people from marginalised groups. “It’s not only the individual who suffers. Without adequate access to rehabilitation, health conditions worsen to the point where more and more pressure is eventually piled on struggling local health systems and other public services. “We desperately need a modernised recovery and rehabilitation service that adequately supports patients following a health crisis and prevents other conditions developing.” Read full story Source: The Guardian, 21 September 2022
  2. News Article
    More than half of maternity units in England fail consistently to meet safety standards, BBC analysis of official statistics shows. Health regulator the Care Quality Commission (CQC) rates 7% of units as posing a high risk of avoidable harm. A further 48% require improvement. The figures are slightly worse than a few years ago, despite several attempts to transform maternity care. The regulator says the pace of improvement has been disappointing. In most cases, pregnancy and birth are a positive and safe experience for women and their families, says the CQC. But when things do go wrong, it is important to understand what happened and whether the outcome could have been different. Laura Ellis lost her newborn son when he was unexpectedly breech during advanced labour. She checked out the CQC rating of her local hospital, Frimley Park, when she was pregnant. Maternity services were good. But Laura didn't realise the unit had been told that it required improvement on safety. Laura said: "It was just so hard. So hard to deal with. So hard to leave as well. How would you leave your baby in hospital when you should be taking them home?" Frimley Park NHS Foundation Trust says it has made a number of changes since Theo died, including an emergency response if a baby is unexpectedly breech during advanced labour. Read full story Source: BBC News, 21 September 2022
  3. News Article
    NHS England has issued a new deadline to treat patients who have been waiting more than two years for treatment, a month after saying it had ‘virtually eliminated’ the longest waits, it has emerged. The goal of no-one waiting more than 104 weeks for treatment by July this year was one of the first milestones in the elective recovery plan hammered out between NHSE and ministers. They were not eliminated by the end of July, but the number was reduced to 3,000, having stood at 22,000 in January. The remaining group consisted of nearly 1,600 patients who had been offered faster treatment elsewhere but did not want to travel, 1,000 who required complex treatment and could not be transferred to another provider and 168 who were not treated by the deadline, according to information issued in the summer by NHSE. Now integrated care systems have been told there is a new “national expectation” to treat the remaining, final two-year waiters by the end of September. HSJ was told the goal has been framed as an ambition rather than a target because it includes patients who have chosen to wait longer. Read full story (paywalled) Source: HSJ, 21 September 2022
  4. Content Article
    The Care Quality Commission provides answers to the following common myths.
  5. News Article
    Moments after unveiling a bill that would ban all abortions in the United States at 15 weeks, US Senator Lindsey Graham was interrupted by a mother with a devastating story. "I did everything right and at 16 weeks we found out that our son would likely not live," Ashbey Beasley told a crowded room. "When he was born, for eight days he bled from every orifice of his body," she said. But, she said, at least she got to choose how to handle her difficult pregnancy, while Mr Graham's law would take away that choice. "What do you say to someone like me?" Since the Supreme Court struck down Roe v Wade this summer, states across the US have pushed through abortion bans or severely restricted the procedure. But as such laws have gone into effect, unintended consequences have followed. Doctors and patients say that confusing standards and the vague language of these laws have had a chilling effect on the medical field in anti-abortion states, leaving tragedies in their wake - and more in the making. For the last year, Amanda Horton, a Texas doctor who specialises in high-risk pregnancies, has struggled to care for patients with pregnancy complications. At times, Dr Horton must inform families that their babies have been diagnosed with a fatal foetal anomaly. These conditions are rare and likely to lead to the death of a foetus in utero, or shortly after birth. But under a strict abortion ban in Texas, her hands are tied. Read full story Source: BBC News, 17 September 2022
  6. News Article
    Sharply rising cases of some sexually transmitted diseases (STDs), including a 26% rise in new syphilis infections reported last year, are prompting US health officials to call for new prevention and treatment efforts. “It is imperative that we ... work to rebuild, innovate, and expand (STD) prevention in the US,” said Leandro Mena of the US Centers for Disease Control and Prevention in a speech on Monday at a medical conference on sexually transmitted diseases. Infections rates for some STDs, including gonorrhoea and syphilis, have been rising for years in the US. Last year the rate of syphilis cases reached its highest since 1991 and the total number of cases hit its highest since 1948. HIV cases are also on the rise, up 16% last year. An international outbreak of monkeypox has further highlighted the nation’s worsening problem with diseases spread mostly through sex. David Harvey, executive director of the National Coalition of STD Directors, called the situation “out of control”. Officials are working on new approaches to the problem, such as home-test kits for some STDs that will make it easier for people to learn they are infected and to take steps to prevent spreading it to others, Mena said. Read full story Source: The Guardian, 20 September 2022
  7. Event
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    This virtual seminar from the Clinical Human Factors Group will be looking at Just Culture and incident investigation and will feature two of the authors, Jan Davies and Carmella Steinke, of the new book 'Fatal Solution' , a book which describes "how a healthcare system used tragedy to transform itself and redefine Just Culture". In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture." To accompany this story Ken Catchpole, Professor of Human Factors at Medical University of South Carolina will discuss a variety of enablers and barriers to learning from clinical safety incidents, based on his perspective within the US health system. This will illustrate the format of incident analysis and response at MUSC; legal and regulatory issues; and the role and impact of human factors and systems engineering. He will also comment on the recent RaDonda Vaught case, and what that tells us about how far we still have to go. Jane O’Hara, Professor of Healthcare Quality and Safety in Leeds will adds a UK perspective to this worldwide issue, together with a session focusing on the view from a pharmacy perspective. Register
  8. News Article
    Britons of black and south Asian origin with dementia die younger and sooner after being diagnosed than white people, research has found. South Asian people die 2.97 years younger and black people 2.66 years younger than their white counterparts, according to a study by academics from University College London and the London School of Hygiene and Tropical Medicine. A team led by Dr Naaheed Mukadam, from UCL’s division of psychiatry, reached their conclusions after studying health records covering the 21 years between 1997 and 2018 of 662,882 people across the UK who were aged over 65. They found that: Dementia rates have increased across all ethnic groups. Black people are 22% more likely to get dementia than their white peers. Dementia is 17% less common among those of south Asian background. But they have voiced concern about also discovering that south Asian and black people are diagnosed younger, survive for less time and die younger than white people. “The earlier age of dementia diagnosis in people of black and south Asian [origin] … may be related to the higher prevalence of some risk factors for dementia such as, in older south Asians, fewer years of education, and in both groups hypertension [high blood pressure], diabetes and obesity,” they write in their paper, published in the medical journal Alzheimer’s & Dementia. Read full story Source: The Guardian, 18 September 2022
  9. Content Article
    Naaheed Mukadam and colleagues investigated the incidence of diagnosed dementia and whether age at diagnosis and survival afterward differs among the UK's three largest ethnic groups. They used primary care electronic health records, linked Hospital Episode Statistics and mortality data for adults aged ≥65 years. They compared recorded dementia incidence 1997–2018, age at diagnosis, survival time and age at death after diagnosis in White, South Asian, and Black people. The study found that dementia incidence was higher in Black people. South Asian and Black people with dementia had a younger age of death than White participants and Black participants. The authors concluded that South Asian and Black peoples’ younger age of diagnosis and death means targeted prevention and care strategies for these groups should be prioritised and tailored to facilitate take-up.
  10. News Article
    Therese Coffey is considering abolishing four-hour A&E waiting time targets as part of her “emergency plan” to tackle the NHS. The new health secretary is understood to be looking at a range of measures to address the growing crisis in the NHS, understood to be announced next Thursday. But a source close to the discussions told The Independent getting rid of the four-hour waits – first suggested in March 2019 – would have to be given the green light by the new prime minister Liz Truss. The announcement will focus on the health secretary’s “ABCD” priorities – standing for “ambulances, backlog, care, dentists and doctors” – with improvements to mental health services as an addition. Policies also being looked at include more call handers for ambulances, more diagnostic community centres, speeding up the hospital building programme, reducing “bureaucratic” burdens on GPs, improving direct access to counselling services for patients and “robust” management of the national dentists’ contract. There is concern among those involved that the move would see the four-hour wait replaced by a new target, which could be as difficult as the current target to achieve. Read full story Source: The Independent, 18 September 2022
  11. News Article
    An ambulance trust accused of withholding key evidence from coroners was previously warned its staff needed training to ‘understand the real risk of committing criminal offences’ in relation to inquests into patient deaths. North East Ambulance Service, which has been accused by whistleblowers of withholding details from coroners in more than 90 deaths, was told by its lawyers in 2019 about serious shortcomings in its processes for disclosing information, according to internal documents obtained by a campaigner. According to the documents, the lawyers said trust staff could “pick and choose” documents to release to coroners “regardless of relevance.” The following year, an audit report said the issues had not been addressed. Whistleblowers’ concerns about the trust were first reported by The Sunday Times in the spring, with a review highlighting several cases between 2018 and 2019 where key facts were omitted in disclosures to coroners. But campaigner Minh Alexander has since obtained new details of warnings that were being made to internally, from lawyers and auditors who were advising the trust. Read full story Source: HSJ, 20 September 2022
  12. News Article
    A nurse in Somerset has been struck off after she failed to give morphine to a patient before they underwent surgery. Amanda-Jane Price had been suspended from front-line duties since the incident in March 2019. The Nursing and Midwifery Council ruled that Miss Price had been "dishonest" with her colleagues and her ability to practice medicine safely was "impaired". Miss Price had been a nurse at Musgrove Park Hospital in Taunton since 2018. On 31 March 2019, Miss Price did not administer morphine to an individual in her care, falsely recording in her notes that morphine had been given. An investigation by the hospital's emergency medicine consultant found that the morphine dose of 6mg had been noted on the patient's chart, but that the drug had not actually been administered. Miss Price subsequently admitted to falsifying the prescription chart, and to "being consciously aware of her decision". As a result of Miss Price's actions, the patient underwent an invasive procedure without analgesia, and subsequently complained of being in pain. The panel concluded that Miss Price was guilty of misconduct and would initially be suspended. "This was deliberate dishonesty which concealed her failure in clinical issues and caused actual patient harm to a vulnerable victim," the panel concluded. Read full story Source: BBC News, 20 September 2022
  13. News Article
    An estimated 1,820 people died in the UK after being given contaminated blood transfusions between 1970 and 1991, a report has found. The findings were published by the public inquiry into the scandal. The long period between infection and symptoms appearing makes it difficult to know how many people were infected through a transfusion in the 1970s and 1980s, before it became possible to screen blood donations for the virus. New modelling for the public inquiry estimated that between 21,300 and 38,800 people were infected after being given a transfusion between 1970 and 1991, with a central estimate of 26,800. The study, by a group of 10 academics commissioned by the public inquiry, calculated that 1,820 of those died as a result, although the number could be as high as 3,320. Its findings were based on the rate of hepatitis C infection in the population, the number of blood donations made over that time, the survival rate of the disease and other factors. It found at least 79 and possibly up to 100 people also contracted HIV through donated blood, based on data provided by the UK Health Security Agency (UKHSA), with most infections between 1985 and 1987. It said 67 people in that group had now died, although there was no data confirming the causes of death. The public inquiry into the infected blood scandal began taking evidence in 2019 and is expected to publish its final report in 2023. Read full story Source: BBC News, 17 September 2022
  14. Content Article
    Investigations of healthcare harm often overlook the valuable insights of patients and families. This review from Lauren et al. aimed to explore the perspectives of key stakeholders when patients and families were involved in serious incident investigations.
  15. Content Article
    Long Covid Support and Long Covid Kids surveyed people with Long Covid about their experience of being reinfected with Covid. Responses were received from 484 adults and 112 children and young people. The study found that reinfection worsens the symptoms of Long Covid in the majority those who are still symptomatic. Reinfection causes a recurrence of Long Covid in 60% of those who were in recovery or remission. 89% of respondents first got Long Covid after their first infection, 10% after their second infection and 1% after their third. Most adult respondents had been vaccinated before their second infection.
  16. Content Article
    More work is needed on understanding and addressing a lack of sleep in rail workers, a new study has argued. Researchers looked at the difference between when staff were on day shifts and when they were working at night. They discovered a “feast and famine” scenario where 41% reported getting six hours of sleep or less when working days, compared to 63% when working nights. The findings, published in the Applied Ergonomics journal, suggested that many staff weren’t getting enough sleep and having less than six hours was linked to feeling very sleepy during the day. More than one in ten shift workers also reported they had been awake for between 18 and 24 hours by the time they finished work at least once during the past week. This led to fears that their tiredness could have an impact on road safety if they were driving home from work. The report said: “Sleep restriction and sleep deprivation, even in the short term, are known to affect cognitive performance. For a safety critical industry, this data should raise a significant concern.”
  17. Content Article
    Healthcare settings are high-risk environments for fatigue and staff burnout. The Need For Recovery (NFR) scale quantifies inter-shift recovery, which contributes to cumulative fatigue and may precede occupational burnout. Advanced clinical practitioners (ACPs) are an established feature of the emergency medicine workforce in the UK, however, little is known about factors affecting their inter-shift recovery, fatigue or how NFR correlates with formal burnout inventories.
  18. Content Article
    Oliver Pittock, managing director of pharmaceutical packaging supplier, Valley Northern, examines the areas of pharmaceutical packaging that require special attention, and how it can contribute towards a future of safer medication. Related content the hub's medication error traps gallery
  19. Content Article
    A blog from the Patients Association for World Patient Safety Day on why patient partnership is key to the safe prescribing, supply and taking of medicines. "Being prescribed medication is one of the most common interactions between patient and healthcare professional: this World Patient Safety, let’s ensure all medicine prescribed today is done so following a discussion of its benefits and risks and with the patient’s full participation."
  20. Content Article
    To mark World Patient Safety Day (WPSD) 2022 and in support of WHO's 5 moments for medication safety, the International Alliance of Patients' Organization (IAPO) has launched the "Humour me into medication safety" cartoons highlighting the 5 moments for medication safety - a patient engagement tool focusing on the key moments where action by the patient or caregiver can reduce the risk of harm associated with the use of medications. It aims to engage and empower patients to be involved in their own care through collaboration with health professionals.
  21. Content Article
    In this blog, Patient Safety Learning marks World Patient Safety Day 2022. It sets out the scale of avoidable harm in health and social care, the need for a transformation in our approach to patient safety and considers the theme of this year’s World Patient Safety Day, medication safety.
  22. Content Article
    Bob Hanscom, J.D., is retiring this week after a nearly 30-year career championing patient safety improvement. He has been Vice President of Risk Management and Analytics at Coverys since 2013 and earlier held similar positions at CRICO and CRICO Strategies. He was Vice President of Clinical Services at Lahey Clinic from 1993 to 1998 and prior to that practiced law.
  23. Content Article
    After more than a decade and half of trying – unsuccessfully – to deal with her fibromyalgia through opioids, Louise finally decided that one way or another, she was going to have to manage her pain another way … In Louise’s words: “I got my life back – I’m living proof that there really is life after opioids!”
  24. Content Article
    The TUC and Long Covid Support Employment Group are interested in the experiences of people with Long Covid. This survey aims to better understand how workers with Long Covid have been treated in the workplace and what support is needed. The survey is for people with Long Covid currently in and out of work. Long Covid is the term used to describe COVID-19 symptoms that extend beyond the initial infection. The survey will take around 15-20 minutes to complete.  
  25. Content Article
    Are you applying Safety-II principles to improve safety in maternity, A&E, ICU or anaesthetics? If so, Dr Ruth Baxter would love to interview you!
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