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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Too often in health and social care poor medication practices and inadequate system infrastructure result in patient harm, with as many as 1 in 10 hospitalisations in OECD countries potentially caused by a medication related event. This report considers the human impact and the economic costs of medication safety events, exploring opportunities to improve systems and policies and how to improve medication safety at a national level.
  2. Event
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    This national learning event will bring together clinical and improvement leaders involved or interested in the Scottish Patient Safety Programme. Aims of the day: Explore the organisational and system wide conditions that enable the safe delivery of care amidst increasing system pressures Learn how The SPSP Essentials of Safe Care are supporting improvements in safety Provide a forum for leaders and teams working across all aspects of SPSP to come together to share and learn This event page is for delegates wishing to attend the morning plenary sessions only as a virtual delegate. Agenda: 10:00 - Chair’s Welcome (Professor Sir Gregor Smith, Chief Medical Officer for Scotland, Scottish Government) 10:10 - Ministerial Address (Maree Todd, Member of the Scottish Parliament & Minister for Public Health, Women’s Health and Sport) 10:25 - SPSP Update (Joanne Matthews, Head of Improvement Support & Safety, Healthcare Improvement Scotland) 10:40 - Plenary Session (Professor Mary Dixon-Woods, Director of THIS Institute & The Health Foundation Professor at the University of Cambridge) 11:25 - Plenary Q&A 11:40 - A System View (Robbie Pearson, Chief Executive, Healthcare Improvement Scotland) 11:50 - Chair’s Summary ((Professor Sir Gregor Smith, Chief Medical Officer for Scotland, Scottish Government) Register
  3. News Article
    Watchdogs have been asked to investigate a Scottish government overhaul of NHS waiting times information after surgeons said that some of the figures were “grossly misleading”. A complaint has been made to the Office for Statistics Regulation, which ensures that important public data is trustworthy, about a new guide for patients on the NHS Inform website. Concerns have also been raised with Audit Scotland, which monitors public spending and NHS performance. Last month Humza Yousaf, Scottish health secretary, unveiled the platform claiming that it would reassure patients about waiting times. But the times given reflect only the experience of patients treated over a three-month period. In orthopaedics, surgeons say, only the most urgent cases are being prioritised while some patients face languishing on waiting lists for years due to lack of capacity. NHS Inform says that people waited a median of 26 weeks between April and June for orthopaedic care, but surgeons argue that this gives a false impression. Dr Iain Kennedy, new chairman of the British Medical Association in Scotland, said the way the figures have been compiled would suggest that people are still not getting a realistic picture of delays. Read full story (paywalled) Source: The Times, 16 September 2022
  4. News Article
    A legal bid to suspend the public inquiry into alleged abuse at Muckamore Abbey hospital has been dismissed by a High court judge. The applicant in the case has been granted anonymity. They challenged Health Minister Robin Swann's refusal to suspend the public inquiry until criminal proceedings against them had concluded. Lawyers argued that the applicant's article six right to a fair trail had been jeopardised. The applicant's lawyers cited "adverse and prejudicial" commentary already in the media. Rejecting the application the judge, Mr Justice Colton, said that the applicant's article six rights were fully protected within the criminal trial process. The judge referred to submissions from the applicant's legal team who had argued that if the inquiry recommences as planned this month, it would consider evidence reported by the media which could affect the ability of a jury to act impartially. The judge told the court there was nothing to suggest that there had been a "virulent media campaign" about the applicant. Read full story Source: BBC News, 15 September 2022
  5. Content Article
    Hardeep Singh, an informatics leader, patient safety advocate and innovator has been awarded the Individual Achievement Award in the 20th John M. Eisenberg Patient Safety and Quality Awards for demonstrating exceptional leadership and scholarship in patient safety and healthcare quality through his substantive lifetime body of work. Eric Thomas speaks to Hardeep in an interview for the Joint Commission Journal on Quality and Patient Safety.
  6. News Article
    A coroner has said she does not understand why frontline workers were not required to wear a mask during lockdown after hearing a paramedic had died with Covid. A two-day inquest into the death of Peter Hart, who died on his 52nd birthday, concluded on Tuesday (September 13) with assistant coroner Dr Karen Henderson ruling the father-of-three died of natural causes caused by Covid. She said on the balance of probabilities he caught the disease while working at East Surrey Hospital, where he died on May 12, 2020. During the onset of the pandemic only healthcare workers tending to those suspected of having Covid-19 were required to wear personal protective equipment (PPE). In accordance with national guidelines, Mr Hart, who was treating patients not suspected of having the virus, did not need to. “Retrospectively it is difficult to comprehend why the national guidance said PPE did not need to be used for all patients and healthcare workers at the earliest opportunity,” Dr Henderson said. “Although there appears a lost opportunity to ensure maximum protection I make no finding of fact whether this contributed to Mr Hart’s death. “Patients not suspected to have Covid were not expected to wear face masks. This is in effect a perfect storm and given evidence of Mrs Hart I am satisfied Mr Hart contracted Covid during his work at East Surrey Hospital,” she added. Read full story Source: Surrey Live, 13 September 2022
  7. Content Article
    Patients, families, and care providers affected by patient safety incidents expect there will be learning and improvement so that others will not suffer. For that, countries need mature data systems and a culture of safety that includes improving by learning from reporting hazards, harm, and near misses, as well as learning from situations and organisations where safe care is delivered consistently over time, which is in most cases. In this article, Ioana Popescu discusses patient safety in Canada. While systems are in place to support incident reporting, sharing, and learning from a variety of sources, in Canada truly national incident reporting is limited to medications, adverse drug reactions, and device failures. However, there are other pan-Canadian and grassroots efforts to advance reporting and learning from patient safety incidents that are complementary. 
  8. News Article
    Police are preparing to investigate alleged mistreatment of patients at a mental health unit. The Edenfield Centre based in the grounds of the former Prestwich Hospital in Bury is at the centre of the claims. The unit cares for adult patients. The Manchester Evening News understands that action was taken after the BBC Panorama programme embedded a reporter undercover in the unit and then presented the NHS Trust which runs it with their evidence. A spokesperson for Greater Manchester Police said: "We are aware of the allegations and are liaising with partner agencies to safeguard vulnerable individuals and obtain all information required to open an investigation." A spokesperson for Greater Manchester Mental Health NHS Foundation Trust said: "We can confirm that BBC Panorama has contacted the Trust, following research it conducted into the Edenfield Centre. We would like to reassure patients, carers, staff, and the public that we are taking the matters raised by the BBC very seriously". "Immediate action has been taken to address the issues raised and to ensure patient safety, which is our utmost priority. We are liaising with partner agencies and stakeholders, including Greater Manchester Police. We are not able to comment any further on these matters at this stage." Read full story Source: Manchester Evening News, 14 September 2022
  9. News Article
    NHS staff have warned that needles supplied with a Covid vaccine which targets the omicron strain are “not fit for purpose” and could place vaccinators and members of the public at risk. Dozens of messages shared on an NHS staff forum reveal widespread concerns about the needles supplied with the Moderna SpikeVax vaccine, which are said to bend when vaccinators pierce the top of the vial containing the Covid-19 vaccine doses. The SpikeVax bivalent vaccine was the first to target both the original and the omicron strain of the virus. It is due to play a key role in the NHS’s autumn Covid vaccination booster programme. One pharmacist said: “They [the needles] just are not fit for purpose and as such we are not using them and are using the original needles until a solution is found”. A UK Health Security Agency spokesperson confirmed the problem, stating: “We are aware that some NHSE sites are experiencing some problems with the use of the new needle and syringe being supplied for administrating the Moderna bivalent vaccine. We are in touch with the supplier about these concerns, including the facilitation of additional training support, but if necessary will also offer an alternative suitable product to avoid any disruption to the vaccination programme.” Read full story (paywalled) Source: HSJ, 15 September 2022
  10. Content Article
    Minutes from the General Pharmaceutical Council meeting held on 14 July 2022. To be confirmed 8 September 2022.
  11. Event
  12. Event
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    The Safe Anaesthesia Liaison Group Patient Safety Conference will be held in collaboration with RA-UK. The first session will include engaging lectures around the current work of SALG, and the second session will focus on topical issues in relation to regional anaesthesia safety. There will be a prize session for accepted abstracts, with a poster section and oral presentations. This online conference is being organised by SALG co-chairs, Dr Peter Young from the Association of Anaesthetists, Dr Felicity Platt, Royal College of Anaesthetists and Nat Haslam, Regional Anaesthesia UK The day will provide valuable knowledge for doctors engaged in clinical anaesthesia, pain management and intensive care medicine, and who have an interest in improving patient safety. Register
  13. News Article
    On Tuesday, the FBI issued a report offering recommendations to address a number of cybersecurity vulnerabilities in active medical devices stemming from outdated software, as well as the lack of security features in older hardware. Once exploited, the vulnerabilities could impact healthcare facility operations, patient safety, data confidentiality and data integrity. If a cyberattacker takes control, they can direct devices to give inaccurate readings, administer drug overdoses or otherwise endanger patient health. The FBI noted in its briefing that a mid-year healthcare cybersecurity analysis found that equipment vulnerable to cyberattacks includes insulin pumps, intracardiac defibrillators, mobile cardiac telemetry, pacemakers, and intrathecal pain pumps. Routine challenges include the use of standardised configurations, specialised configurations – including a substantial number of managed devices on a network – and the inability to upgrade device security features, according to the FBI's announcement. The agency further adds that research has found an average of 6.2 vulnerabilities per medical device and that 40% of medical devices at the end-of-life stage offer little to no security patches or upgrades. Read full story Source: Healthcare IT News, 13 September 2022
  14. Content Article
    On 25 March 2020, Hannah Davis was texting with two friends when she realized that she couldn’t understand one of their messages. In hindsight, that was the first sign that she had COVID-19. It was also her first experience with the phenomenon known as “brain fog,” and the moment when her old life contracted into her current one. She once worked in artificial intelligence and analysed complex systems without hesitation, but now “runs into a mental wall” when faced with tasks as simple as filling out forms. Her memory, once vivid, feels frayed and fleeting. Former mundanities—buying food, making meals, cleaning up—can be agonisingly difficult. For more than 900 days, while other long-COVID symptoms have waxed and waned, her brain fog has never really lifted.
  15. News Article
    The Leapfrog Group will add a section to its annual survey in 2024 asking US hospitals to report their progress on evidence-based practices designed to prevent and reduce patient injury and death from diagnostic error and delay. This Autumn, Leapfrog will pilot test survey questions about a range of diagnostic practices from holding leaders accountable for diagnostic safety to openly communicating diagnostic errors to patients and optimising electronic records to support accurate and timely diagnosis. Results of the Leapfrog Hospital Survey — completed voluntarily each year by more than 2,300 U.S. hospitals — rate participants’ progress toward Leapfrog’s standards for safety, quality and transparency and are publicly reported. Since 2000, the survey has been the centerpiece of Leapfrog’s mission to “support informed health care decisions and promote high-value care.” The results are also used by hospitals to benchmark their performance to others in the industry. The addition to the survery is part of a larger push to reduce harm caused by diagnostic error. Leapfrog is working with the Society to Improve Diagnosis in Medicine (SIDM) on a multi-year project called “Recognizing Excellence in Diagnosis.” Mark L. Graber, SIDM’s Founder and President Emeritus, expects that including diagnosis in the survey will elevate organizations’ interest in addressing diagnostic error. “Healthcare organizations need to address the harm arising from diagnostic error in their own hospitals.” says Dr. Graber. “The new Leapfrog report gives them ideas on where to start.” Read full story Source: Betsey Lehman Center, 14 September 2022
  16. News Article
    The global response to the first two years of the Covid-19 outbreak failed to control a pandemic that has led to an estimated 17.7 million deaths to date, a major review has concluded. The Lancet Commission on lessons for the future from the Covid-19 pandemic, produced by 28 world leading experts and 100 contributors, cites widespread failures regarding prevention, transparency, rationality, standard public health practice, operational coordination, and global solidarity. It concludes that multilateral cooperation must improve to end the pandemic and manage future global health threats effectively. The commission’s chair, Jeffrey Sachs, who is a professor at Columbia University and president of the Sustainable Development Solutions Network, said, “The staggering human toll of the first two years of the Covid-19 pandemic is a profound tragedy and a massive societal failure at multiple levels.”In its report, which used data from the first two years of the pandemic and new epidemiological and financial analyses, the commission concludes that government responses lacked preparedness, were too slow, paid too little attention to vulnerable groups, and were hampered by misinformation.Read full story Source: BMJ, 14 September 2022
  17. Content Article
    As of May 31, 2022, there were 6·9 million reported deaths and 17.2 million estimated deaths from COVID-19, as reported by the Institute for Health Metrics and Evaluation. The Lancet COVID-19 Commission was established in July 2020, with four main themes: developing recommendations on how to best suppress the epidemic; addressing the humanitarian crises arising from the pandemic; addressing the financial and economic crises resulting from the pandemic; and rebuilding an inclusive, fair, and sustainable world. It has now published it's key findings and recommendations.
  18. News Article
    Trust staff have been warned that an independent investigation into maternity services will be ‘a harrowing read’ with a ‘profound and significant impact’. The report into services at East Kent Hospitals University Foundation Trust between 2009 and 2020 had been expected to be published on Wednesday 21 September. However, this morning families involved in the investigation received an email saying publication would be postponed to an unknown date in October.. Next Wednesday, when the report was expected to be released and a statement made to Parliament, has been set aside for all MPs to take an oath of allegiance to King Charles III. An email sent to staff at East Kent last week and seen by HSJ said publication would place “significant focus on the trust and all of our services”, and that the trust would make support available to staff as well as former, current and potential patients. The trust will not see the report before publication. The investigation – led by Dr Bill Kirkup, who also led the Morecambe Bay maternity investigation – was prompted by the death of week-old Harry Richford after a traumatic birth at the trust’s Queen Elizabeth, the Queen Mother, Hospital in Thanet in 2017. Around 200 families are thought to have contacted the investigation team with concerns around maternity care. Read full story (paywalled) Source: HSJ, 15 September 2022
  19. News Article
    Some women in Northern Ireland are waiting more than three times longer than they should for smear test results. BBC News NI's Evening Extra programme learned that all health trusts were breaching the target of 80% of samples being reported within four weeks. The Department of Health (DoH) and Public Health Agency (PHA) said it was due to pressures on pathology services. This included a shortage of available trained staff across the UK to carry out the screening, they said. Unlike the rest of the UK, each sample in Northern Ireland has to be individually examined by a scientist. In Great Britain, HPV primary screening is used. This tests the sample of cells taken at the appointment for a virus that can cause cervical cell changes to develop into cancer. The DoH said it intended to implement this in Northern Ireland and the project involved significant work to reconfigure services. Read full story Source: BBC News, 15 September 2022
  20. News Article
    Doctors suffering from burnout are far more likely to be involved in incidents where patients’ safety is compromised, a global study has found. Burned-out medics are also much more likely to consider quitting, regret choosing medicine as their career, be dissatisfied with their job and receive low satisfaction ratings from patients. The findings, published in the BMJ, have raised fresh concern over the welfare and pressures on doctors in the NHS, given the extensive evidence that many are experiencing stress and exhaustion due to overwork. A joint team of British and Greek researchers analysed 170 previous observational studies of the links between burnout among doctors, their career engagement and quality of patient care. Those papers were based on the views and experience of 239,246 doctors in countries including the US, UK and others in Africa, Asia and elsewhere globally. They found that burned-out medics were twice as likely as their peers to have been involved in patient safety incidents, to show low levels of professionalism and to have been rated poorly by patients for the quality of the care they have provided. Doctors aged 20 to 30 and those working in A&E or intensive care were most likely to have burnout. It was defined as comprising emotional exhaustion, depersonalisation – a “negative, callous” detachment from their job – and a sense of reduced personal accomplishment. Read full story Source: The Guardian, 14 September 2022
  21. Content Article
    A systematic review and meta-analysis from Hodkinson et al. examines the association of physician burnout with the career engagement and the quality of patient care globally. A joint team of British and Greek researchers analysed 170 previous observational studies of the links between burnout among doctors, their career engagement and quality of patient care. Those papers were based on the views and experience of 239,246 doctors in countries including the US, UK and others in Africa, Asia and elsewhere globally. This meta-analysis provides compelling evidence that physician burnout is associated with poor function and sustainability of healthcare organisations primarily by contributing to the career disengagement and turnover of physicians and secondarily by reducing the quality of patient care. Healthcare organisations should invest more time and effort in implementing evidence-based strategies to mitigate physician burnout across specialties, and particularly in emergency medicine and for physicians in training or residency. Read accompanying BMJ editorial here.
  22. News Article
    The midwife leading a review into failings by Nottingham's maternity services said the scope was wider than the UK's biggest maternity scandal. Donna Ockenden previously led the review at Shrewsbury and Telford NHS Trust that found failings led to the deaths of more than 200 babies. The terms of reference for the review in Nottingham were set out on Tuesday. A category of severe maternal harm has been added to include cases that did not lead to a death or injury. Earlier this year Ms Ockenden completed her inquiry into the UK's biggest maternity scandal at Shrewsbury and Telford NHS Trust. She said the scope of the review in Nottingham was wider because an additional category had been added to the investigation. It aims to identify cases of severe maternal harm, like an unexpected admission to intensive care or a major obstetric haemorrhage. Ms Ockenden said: "We felt adding in the category of severe maternal harm would help us to understand women's experiences and help us to learn and help the trust to learn from those cases as well. "So actually there's been a widening of the scope which our review team felt was important and when we tested it out with some families they felt it was important too. "Perhaps there's a mum out there saying 'well I'm ok, and my baby's ok, but x,w,z of my maternity experience really worried me or frightened me' then she can send in her experiences." She said fathers could also send in their experiences. Read full story Source: BBC News, 14 September 2022
  23. Content Article
    To provide high quality services in increasingly complex, constantly changing circumstances, healthcare organisations worldwide need a high level of resilience, to adapt and respond to challenges and changes at all system levels. For healthcare organisations to strengthen their resilience, a significant level of continuous learning is required. Given the interdependence required amongst healthcare professionals and stakeholders when providing healthcare, this learning needs to be collaborative, as a prerequisite to operationalising resilience in healthcare. As particular elements of collaborative working, and learning are likely to promote resilience, there is a need to explore the underlying collaborative learning mechanisms and how and why collaborations occur during adaptations and responses. The aim of this study from Haraldseid-Driftland et al. was to describe collaborative learning processes in relation to resilient healthcare based on an investigation of narratives developed from studies representing diverse healthcare contexts and levels.
  24. Content Article
    Perceptions of care work as low skilled continue to persist, despite the pandemic highlighting just how vital care workers are. In recent years there has been increased debate around the ‘professionalisation’ of this staff group, which generally refers to the creation of a statutory register of staff and their professional regulation. This new Nuffield Trust report reviews what the evidence shows about the professionalisation of care workers in other countries.
  25. Content Article
    Understanding myalgic encephalomyelitis/chronic fatigue syndrome—an elusive condition that often follows an infection and shares many similarities with Long Covid—could improve Long COVID19 research, argues a new Science Perspective.
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