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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Unsafe maternity care has cost the National Health Service in England (NHS) £8.2bn in 15 years. How many more surveys of women’s experiences, reports of poor quality care and failings of senior management at NHS maternity units do we need to know that there is still a massive problem with maternity services in England? Judy Shakespeare, Elizabeth Duff and Debra Bick discuss why a joined-up policy and investment in maternity services is urgently needed.
  2. Content Article
    Specialist inspectors have identified cases of Salbutamol inhaler overprescribing of up to six inhalers per prescription by online prescribers. This article explores the risks of prescribing high volumes of Salbutamol inhalers. It highlights the need for ongoing patient monitoring, counselling advice, inhaler device choices and discuss the clinical considerations when continuing treatment.
  3. News Article
    Multiple professional and research communities feel a profound loss at the death of Richard I. Cook. Richard died peacefully at home on August 31, 2022 in the loving care of his wife Karen and his family. Dr Richard Cook was a polymath who excelled in multiple careers, usually simultaneously. A physician and anaesthesiologist, he was committed to providing personal, safe, and superb care to his patients. Richard was a Clinical Practitioner, Professor, Field Researcher, Human Factors specialist, Cognitive Systems Engineer, Designer of human-automation systems, Patient Safety Advocate, Change Agent, Teacher, Author, Innovator, Software Engineer, Pioneer of new fields such as Resilience Engineering. As a polymath, he was all of these, because by doing each, he learned more about all. Because he was committed to learning by doing, learning by detailed study of work as done, learning through interdisciplinary inquiry, and learning at the intersections, he was able to build unique expertise that broke traditional categories. This rare form of expertise mattered because he used it to create safety in health care and elsewhere, to lead R&D in unexplored directions, reject intellectual superficiality, and inspire a new generation of researchers, faculty and designers. Read the full obituary Source: Adaptive Creative Labs, 12 September 2022
  4. Event
    Future Surgery, brings together surgeons, anaesthetists and the whole perioperative team. Designed specifically to meet the training needs, promote networking and develop a stronger voice for all surgical professionals and their multidisciplinary teams in perioperative care. Our CPD accredited speaker programme explores disruptive technology, connectivity, human factors, training and research to support the transformation of the profession and the improved care and safety of patients. Future Surgery is the biggest gathering of surgical and operating theatre teams with over 110 expert speakers – in keynote sessions, panel discussions and workshop sessions, covering all that is new in the field of surgery. Register
  5. Event
    This Westminster conference will discuss the strategic priorities for tackling overprescribing in the NHS. It follows NHS England’s overprescribing review and subsequent Good for You, Good for Us, Good for Everybody action plan. Delegates will discuss what would be needed if the plan’s aims for systemic and cultural change are to be achieved, and priorities for the proposed Clinical Director for Prescribing. It will be an opportunity to discuss the future of medicines optimisation, opportunities for social prescribing, and measures to enable consistent delivery across the whole population and to expand the workforce to deliver non-medical treatments where possible. Key areas for discussion include: culture change - including development of leadership and accountability around overprescribing at national and ICS level - key issues for the Clinical Director for Prescribing systemic change - the role of social prescribing - strategic priorities for medicines optimisation - practicalities of scaling up: funding, staffing, training, and engagement with patients patient-centred care - practical steps - involving patients with managing long-term conditions - building support and frameworks required for development research - sharing best practice and guidance - building the evidence base - developing understanding of the groups most impacted digital - the role of digital transformation in supporting patient-centred care and the ability to make more informed care decisions - improvements to patient records pharma - system-wide collaboration and industry transparency. Agenda Register
  6. Event
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    The concerns about the state and stability of the NHS were deeply entrenched before 2020 and then of course the pandemic hit. The additional pressures and longer waiting times for appointments and treatment have only grown following a time when the NHS staff have experienced stresses like they never have before. The situation has led to increased fears of privatisation and increasing staff shortages as so many seek work elsewhere. But where does this leave our national health service and what does the future hold for a life saving institution which is struggling to survive itself? Join the Independent’s latest panel discussion as part of our virtual event series where our health correspondent Rebecca Thomas will ask a panel of experts including Dr Alexis Paton, director at the Centre for Health and Society, Hannah Barham-Brown, a GP and also deputy leader of the Women’s Equality Party and Dr Suzanne Tyler, RCM's Executive Director, Trade Union, about how they think the NHS can be healed and how it’s future can be secured. Register
  7. News Article
    Thousands of hospital and GP appointments have been cancelled due to the public holiday surrounding the Queen's funeral on Monday. Many hospitals are to postpone outpatient appointments and planned operations because of reduced staffing, while most GP surgeries will also close. NHS hospitals in England have been urged to contact patients who could be affected, whether or not their appointment has been postponed. Some hospitals have said they will be operating as usual, while others have said that they will postpone some non-urgent appointments. Some patients and doctors have expressed concern about their appointments being postponed. One doctor told The Independent: “I have the greatest respect for the Queen ... but when patients are waiting up to two years to be seen ... really? One GP leader in London said practice staff were now getting “abuse” over the bank holiday closures. Read full story Source: The Independent, 14 September 2022
  8. News Article
    A major acute site has issued a ‘full capacity’ alert to staff, just days before the services are due to move into a replacement hospital with fewer beds. In an email seen by HSJ, medical leaders at the Royal Liverpool Hospital alerted staff to extreme pressures on the site, with ambulances being held outside and “no space” in resuscitation areas. The RLH currently has around 685 beds, but at the end of this month the services are due to start transferring to the long-awaited new Royal Liverpool, on an adjacent site. The new hospital has 640 beds, and several frontline staff have told HSJ this is causing significant concern, with the current services under so much pressure. One senior source at the trust said there has been a push since 2017 to reduce inpatients beds at the current hospital, to try and match the capacity of the new build, but this hasn’t been achieved. They added: “Surgeons are concerned that their beds will get filled with medical outliers. The whole issue is all the patients who are waiting for social care. It was supposed to have been sorted by now.” Read full story (paywalled) Source: HSJ, 13 September 2022
  9. News Article
    The World Health Organization (WHO) and almost 200 other health associations have made an unprecedented call for a global fossil fuel non-proliferation treaty. A call to action published on Wednesday, urges governments to agree a legally binding plan to phase out fossil fuel exploration and production, similar to the framework convention on tobacco, which was negotiated under the WHO’s auspices in 2003. “The modern addiction to fossil fuels is not just an act of environmental vandalism. From the health perspective, it is an act of self-sabotage,” said the WHO president, Dr Tedros Adhanom Ghebreyesus. Diarmid Campbell-Lendrum, the head of the WHO’s climate change department, said the letter was a watershed moment. “This is the first time the health sector has come together to issue such a statement explicitly about fossil fuels,” he told the Guardian. “The current burden of death and disease from air pollution is comparable to that of tobacco use, while the long-term effects of fossil fuels on the Earth’s climate present an existential threat to humanity – as do nuclear weapons.” Read full story Source: The Guardian, 14 September 2022 Further reading Climate change: why it needs to be on every Trust's agenda
  10. Content Article
    How do we improve in the face of complexity? Atul Gawande has studied this question with a surgeon's precision. He shares what he's found to be the key: having a good coach to provide a more accurate picture of our reality, to instill positive habits of thinking, and to break our actions down and then help us build them back up again. "It's not how good you are now; it's how good you're going to be that really matters," Gawande says.
  11. Content Article
    There are rising reports of profound cognitive impairment on par with clinical dementia as a result of Long Covid. By researchers’ best estimates, more than 1 in 8 people with Covid-19 will have some array of the 200 odd symptoms reported in this disease for months to years. Long Covid is quickly emerging as the next public health challenge. What are these land mines left behind by the SARS-CoV-2 virus? Are you at risk for them to explode even if you never get very sick from Covid? A study released earlier this month suggests that people suffering from long COVID end up with reservoirs of active SARS-CoV-2 virus — documented in our lungs, brain, and GI tract — which produce ongoing levels of viral spike protein in the blood. A year after becoming infected, patients’ levels can sometimes remain as high as were found during early infection.
  12. Content Article
    A handful of immunologists are pushing the field to take attributes such as sex chromosomes, sex hormones, and reproductive tissues into account.
  13. Content Article
    Copy of the speech from Helen Hughes, Chief Executive of Patient Safety Learning, given at the Professional Standards Authority for Health and Social Care (PSA) Parliamentary launch of the publication 'Safer care for all - Solutions from professional regulation and beyond'.
  14. News Article
    About 15,000 nurses in Minnesota walked off the job Monday to protest understaffing and overwork — marking the largest strike of private-sector nurses in U.S. history. Slated to last three days, the strike spotlights nationwide nursing shortages exacerbated by the coronavirus pandemic that often result in patients not receiving adequate care. Minnesota nurses charge that some units go without a lead nurse on duty and that nurses fresh out of school are delegated assignments typically held by more experienced nurses, across some 16 hospitals where strikes are expected. The nurses are demanding a role in staffing plans, changes to shift scheduling practices and higher wages. “I can’t give my patients the care they deserve,” said Chris Rubesch, the vice president of the Minnesota Nurses Association and a nurse at Essentia Health in Duluth. “Call lights go unanswered. Patients should only be waiting for a few seconds or minutes if they’ve soiled themselves or their oxygen came unplugged or they need to go to the bathroom, but that can take 10 minutes or more. Those are things that can’t wait.” Read full story (paywalled) Source: Washington Post, 12 September 2022
  15. News Article
    Over the past couple of months, deaths in England and Wales have been higher than would be expected for a typical summer. In July and August, there were several weeks with deaths 10% to 13% above the five-year average, meaning that in England about 900 extra people a week were dying compared with the past few years. The leading causes of death are within the typical range (the five-year average): heart and lung diseases, cancers, dementia and Alzheimer’s disease. Covid-19 deaths could account for half of the excess mortality, but the other half is puzzling, as there’s no one clear reason that jumps out. It’s likely to be a mix of factors: Covid is making us sicker and more vulnerable to other diseases (research suggests it may contribute to delayed heart attacks, strokes, and dementia); an ageing population; an extremely hot summer; and an overloaded health service meaning that people are dying from lack of timely medical care. The excess mortality puzzle has been weaponised by some to argue that this is a delayed consequence of lockdown. In essence, this is to say that mandatory restrictions on mixing and stay-at-home legal orders, as well as turning the NHS into a Covid health service during the first and second waves of infection, prevented people from being diagnosed or treated for other conditions such as cancer, heart disease, or even depression – and that those long-hidden conditions are now killing people. Read full story Source: The Guardian, 13 September 2022
  16. News Article
    The American Medical Association and three other major health groups have warned that patients across the nation could suffer “irreparable harm” due to the shattered legal landscape left in the wake of the Supreme Court’s decision to overturn Roe v. Wade. In a statement, co-authored with the American Pharmacists Association, the American Society of Health-Systems Pharmacists and the National Community Pharmacists Association, the groups said they were deeply concerned by state efforts to limit access to medically necessary medicine. Ongoing questions about state laws are already impacting patients, and language in newly enacted rules is “vague,” “unclear” and “disrupting care,” they said. “Physicians, pharmacists, and other health care professionals face a confusing legal landscape due to state laws’ lack of clarity, confusing language, and unknown implementation by regulatory and enforcement bodies,” the statement reads. “Without such guidance, we are deeply concerned that our patients will lose access to care and suffer irreparable harm.” The groups pointed to reports that some hospitals had prioritised caution over healthcare, others that have removed emergency contraceptives from kits for victims of sexual assault and pharmacies that have imposed “burdensome” steps for prescriptions. Read full story Source: HuffPost, 9 September 2022
  17. Content Article
    In this article, Dr Diane Ashiru-Oredope and Eleanor Harvey from the UK Health Security Agency identify the risks of prescribing and dispensing oral antimicrobials and consider how pharmacy teams can minimise antimicrobial resistance.
  18. News Article
    NHS bosses have been told to make sure patients can access care if GPs close on the day of the Queen's funeral. NHS England has written to local bosses saying while GP services will be able to close on the bank holiday there needs to be enough out-of-hours care. The letter also asked for scheduled Covid booster care home visits to be carried out as planned. In another letter to hospitals NHS England said it expected a rise in patients not turning up for clinics. There have been reports of some hospitals in England and other parts of the UK cancelling routine treatments due to take place on the day of the funeral too. The letter addressing GP access, signed by NHS England's director of primary care Dr Ursula Montgomery, said GP practices would be contractually able to close their core services on Monday as its a confirmed bank holiday. But it added local health boards would need to "urgently work to ensure sufficient out-of-hours services capacity is in place". The letter also said areas must make up for cancelled appointments by offering patients another appointment within two weeks and make sure patients can pick up prescriptions in advance. Read full story Source: BBC News, 12 September 2022
  19. News Article
    Hardeep Singh, an informatics leader, patient safety advocate and innovator, and friend of the Jewish Healthcare Foundation (JHF), 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. The Joint Commission and National Quality Forum present Eisenberg Awards annually to recognise major achievements to improve patient safety and healthcare quality. Dr Singh, chief of the Health Policy, Quality & Informatics Program in the Center for Innovations in Quality, Effectiveness and Safety at Michael E. DeBakey VA Medical Center and professor at Baylor College of Medicine, was recognised for his pioneering career in diagnostic and health IT safety and his commitment to translating his research into pragmatic tools, strategies, and innovations for improving patient safety. His commitment to improving patient safety began while pursuing his Master of Public Health at the Medical College of Wisconsin in 2002 when he first learned the field of patient safety existed. That commitment was galvanised early in his medical career, as he found himself treating patients who had been misdiagnosed, received unsafe care, or experienced poor outcomes. The breadth and depth of Dr Singh's research work is remarkable, but what is most notable is the extent to which he has succeeded in translating it into pragmatic strategies and innovations for improving patient safety. Dr. Singh emphasised that while the Eisenberg Award recognizes an individual for their achievements, his work in patient safety has been successful because of its multi-disciplinary and collaborative approach with psychologists, human factors engineers, social scientists, informaticians, patients, and more. That work has led to the development of several tools to improve patient safety, including The Safer Dx Checklist, which helps organizations perform proactive self-assessment on where they stand in terms of diagnostic safety. "As an immigrant and an international medical graduate, I have had a lifelong dream to make an impact on health care. I saw every scientific project as an opportunity to change health care. So, I made a personal commitment that my research must use a pragmatic, real-world improvement lens and challenge the status quo in quality and safety," Dr. Singh said. Read full story Source: Jewish Healthcare Foundation News, 31 August 2022
  20. Content Article
    With Liz Truss becoming the new Prime Minister today after winning the Tory leadership contest, what are the health and care commitments from the 2019 Conservative Party Manifesto that she inherits? Mark Dayan, Lucina Rolewicz and Jessica Morris explore the progress of the main health and care promises that were made. Which are on course to be delivered and which are not?
  21. News Article
    Merope Mills’s recent article in the Guardian should be mandatory reading for all medical and nursing students. All of us who are senior doctors or nurses will recognise only too well the dangerous conditions that Merope describes: the senior doctors with overinflated egos; the internecine warfare between departments; the nursing staff and junior doctors who are rendered impotent by repeated attempts to galvanise action from off-site but know-it-all seniors; the lack of integrated thinking that results when there is no consistent lead clinician; and, most dangerous, not listening to the patient or their relatives, and not directly examining the patient. Candour and co-production are terms much used in healthcare, but for some staff these aspects of care are a million miles away from the ego-driven practice in which they engage. This is why Merope’s advice is so important. Do not have blind faith in your clinician. Do not leave all the thinking to them. Do equip yourself with knowledge and, most of all, do demand to be treated as an equal partner in the care of your body or your loved one. Current and former healthcare professionals respond to Merope Mills’s account of losing her daughter after a series of catastrophic medical errors. Read full story Source: The Guardian, 11 September 2022
  22. News Article
    There was a fair bit of press coverage last week about an employment tribunal case against the Care Quality Commission – in which the regulator was found to have sacked an inspector for making a series of whistleblowing disclosures. However, many of the key details were either skirted over, or missed altogether, in the coverage. The disclosures made by Shyam Kumar related not just to his role as a special adviser for the CQC, but also to his full-time employer, University Hospitals of Morecambe Bay FT, and to understand the case fully, they need to be separated out. The important context (also skirted over) was that Dr Kumar had raised a series of legitimate concerns about another orthopaedic surgeon at UHMB, both internally within the trust, and externally with the CQC, in 2018. This caused major tensions within UHMB, to the extent that Dr Kumar started to be targeted for criticism by a different surgeon, being labelled a ‘traitor’ to Indian doctors in a group email. When challenged by Dr Kumar, the colleague complained to the CQC that Dr Kumar had sought to threaten and intimidate him, along with other accusations. Read full story (paywalled) Source: HSJ, 12 September 2022
  23. News Article
    At least 12,000 people were treated for sepsis in hospitals in Ireland last year, with one in five of those dying from the life-threatening condition. However, the HSE said the total number of cases is likely to be much higher. Marking World Sepsis Day, it said the condition kills more people each year than heart attacks, stroke or almost any cancer. The illness usually starts as a simple infection which leads to an “abnormal immune response” that can “overwhelm the patient and impair or destroy the function of any of the organs in the body”. Dr Michael O’Dwyer, the HSE’s sepsis clinical lead, said: “The most effective way to reduce deaths from sepsis is by prevention. “A healthy lifestyle with moderate exercise, good personal hygiene, good sanitation, breastfeeding when possible, avoiding unnecessary antibiotics and being vaccinated for preventable infections all play a role in preventing sepsis. “Early recognition and then seeking prompt treatment is key to survival. Recognising sepsis is notoriously difficult and the condition can progress rapidly over hours or sometimes evolve slowly over days.” Read full story Source: Independent Ireland, 13 September 2022 hub resources on sepsis RCNi: Sepsis resource collection NSW Clinical Excellence Commission - Sepsis toolkit Dr Ron Daniels video: Recognising sepsis Introducing the Suspicion of Sepsis Insights Dashboard
  24. Content Article
    We put a lot of trust in the medical profession. We are usually going to the doctor at our most vulnerable—when we don’t feel well, something is wrong, and we need help. It can be a frightening experience that can become a frustrating or even dangerous one when medical concerns are minimized or dismissed. However, there are steps patients can take to advocate for themselves in a medical setting to reduce the risk of medical gaslighting.
  25. Community Post
    Some more examples of hospital's Call 4 Concern leaflets: University Hospitals Dorset - Call 4 Concern leaflet University Hospitals Sussex - Call 4 Concern leaflet East Suffolk and North Essex - Call 4 Concern County Durham and Darlington - Call 4 Concern leaflet Call 4 Concern leaflet - Royal Berkshire NHS Foundation Trust Call 4 Concern: Frimley Health We'd love you to share yours. Just add it to the comments field below.
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