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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Dee Dickens, 52, from Pontypridd, made the difficult choice to seek private healthcare even though she is ideologically opposed to it. After discovering a lump in her breast she was referred for a scan on the NHS’s two-week rule for suspected cancer. But after waiting six weeks, and being continually being told the waiting time was going up, eventually to a three-month wait, she was forced to pay for her own scan and appointment privately. “In February last year, I found a lump in my breast, and went to the doctor that day. The doctor examined me and said, ‘I don’t like that.’ She said the lump was the size of the top of her index finger and she would rush me through for an urgent screening that would take no longer than two weeks. “Two weeks later, I’d heard nothing so I gave them a call. They said that because of Covid, things had slowed down and it might take four weeks. “A week later, one of my breasts had swelled up. It was itching and hot and it felt like it was infected. I felt unwell, too. But I was stressed to the gills. Every day, I was worried I was going to die. We know that we’re against the clock when it’s cancer. “I went straight back to the doctor and she rang the hospital. They said, ‘We will put your patient right at the top of the waiting list, but it will now be six weeks.’ “At six weeks, I still hadn’t heard anything, so I called the hospital. They said that I was at the top of the list still, but it would now be 10 weeks. The wait was going up because, during the worst of Covid, they hadn’t seen anyone so they were now on catchup." “I’d had enough. Every single day I was more and more worried and my mental health was worse and worse, and my family was having to deal with me crying over stupid things. been talking about going private. But I’d been resistant – we’re both very leftwing and believe passionately in the NHS. However, in the Dee made an appointment with a private clinic. She was seen immediately. “After the scan, the doctor told me that the lumps were glandular tissue. The swelling, the pain and itching – were all stress related. As soon as he said, ‘You’re not going to die,’ they stopped. “The NHS is the only thing I’m truly proud of in the UK. What worries me is I can see it disappearing, if not in my lifetime then in my children’s lifetime. That’s one of the reasons I didn’t want to go private. It felt absolutely awful to have to make the choice I did. “On the one hand, I knew I would have an answer. But on the other, I knew there were so many women who wouldn’t be able to do what I was doing. I felt guilty, I felt I’d put my own life above my principles." Read full story Source: The Guardian, 11 September 2022
  2. Content Article
    Call 4 Concern enables patients, relatives and carers to call for help/advice from the Acute Intervention Team when they are concerned about a patient’s condition, and/or they feel that their concern is not being addressed by the ward team. County Durham and Darlington share their Call 4 Concern leaflet.
  3. Content Article
    In this insightful and informative review by Dr Shaffi from Cleveland Clinic learn how you can target Zero catheter-associated urinary tract infections (CAUTI) through close attention to practice - from patient selection through management of the catheter lifecycle and delivery of data driven practice learn the changes that matter.
  4. Content Article
    The SAFER Guides consist of nine guides organiaed into three broad groups. These guides enable healthcare organisations to address electronic health record (EHR) safety in a variety of areas. Most organisations will want to start with the Foundational Guides, and proceed from there to address their areas of greatest interest or concern.
  5. Event
    This Westminster conference will discuss the next steps for addressing rising clinical negligence costs in the NHS. It will be an opportunity to examine the future direction for reform, following the government consultation on lower value clinical negligence claims. Sessions focus on the way forward for learning from mistakes and litigation, improving patient safety, and supporting healthcare staff involved in clinical negligence claims. Delegates will also examine options for streamlining the processing of claims, international best practice, and the potential for moving towards a no-fault system proposed by the Health and Social Care Committee. Overall, areas for discussion include: the current landscape - assessing the factors driving rising clinical negligence costs - the impact of the COVID-19 pandemic on increased risk of claims from diagnosis and treatment delays impact of policy developments - including the increasing use of technology and the move to integrated care - addressing variation and inequalities - changes in the Health and Care Act next steps - priorities for the development of approaches that encourage the health system to learn from mistakes - assessing the potential impact of a no fault system efficiency: opportunities to improve the timeliness and cost-effectiveness of claims resolution the potential for a mandatory system of fixed recoverable costs in low value claims implications for the future direction of system reforms patient safety and protecting healthcare staff - next steps for learning from claims - developing collective learning - using best practice guidelines - support for the ethnic minority workforce international examples - lessons from approaches to clinical negligence claims in other countries - how they might be applied effectively in England NHS Resolution’s strategy to 2025 - which sets out aims to reduce harm, distress and costs, and use indemnity arrangements to drive change across the health system. Agenda Registration
  6. Event
    Govconnect are delighted to announce that the 3rd Annual Improving Patient Safety & Care Conference, will be held at the RSM in partnership with Patient Safety Learning. Supporting STPs/ICSs and healthcare providers to implement features of the NHS Patient Safety Strategy can only be achieved through the joint efforts of multiple organisations, and for the last 3 years, the Govconnect’s Patient Safety series of webinars has provided the platform for discussion to shape a better policy in order to better deliver the commitments of the strategy. Improving Patient Safety & Care 2022 allows government departments, arms-length bodies, the NHS and local authorities, research institutions, and the charity and voluntary sector to hear from senior leaders from many of the key partner organisations involved in implementing the patient safety strategy. Speakers at this event include: Dr Una Adderley, National Wound Care Strategy Programme Director, AHSN Network Cheryl Crocker, Patient Safety Director, AHSN Network Sir Robert Francis, Chair, Healthwatch England Dr Nigel Acheson, Deputy Chief Inspector of Hospitals, Care Quality Commission Helen Hughes, Chief Executive Officer, Patient Safety Learning Peter Walsh, Chief Executive, Action Against Medical Accidents & WHO Patients for Patient Safety Champion Agenda Register We are delighted to announce we have a number of fully funded tickets to offer. Please use the following code when asked at the cart on the registration page: IPSC22GUEST
  7. News Article
    More than 350 families have already contacted a review team which is examining failings at maternity units in two Nottingham hospitals. The review was opened on 1 September by Donna Ockenden, who previously led an inquiry into the maternity scandal at Shrewsbury and Telford NHS Trust. She will examine how dozens of babies died or were injured in Nottingham. Nottingham University Hospitals NHS Trust has apologised for "unimaginable distress" caused by its failings. More affected families, as well as staff with concerns, have been asked to come forward. Ms Ockenden said: "We are really pleased with the large numbers of families and staff that have already come forward in the first week of the review, and we actively encourage others to do the same." Read full story Source: BBC News, 12 September 2022
  8. News Article
    Millions of patients are being forced to pay for private healthcare amid record NHS waiting lists and are having to cut spending, raid savings or get into debt to fund it, new research reveals. One in 10 (10%) adults in the UK have turned to the private sector or independent healthcare in just the last 12 months, according to a survey commissioned by charity Engage Britain. Of those, almost two-thirds (63%) did so because they faced long delays or could not access treatment on the NHS. The latest NHS England figures show the number of people in England waiting for routine hospital treatments has jumped to a record 6.8 million. Of those who have gone private, almost half (46%) were forced to reduce their spending in other areas, plunder savings they had been keeping for another purpose, or get into financial debt to pay for it. Miriam Levin, health and care programme director at Engage Britain, said: “While the NHS still unites many of us with a feeling of pride, it’s clear more and more people feel forced to turn to private treatment. “As people suffer through months of pain and discomfort after postponed appointments, or waste time and energy chasing up referrals, millions are feeling desperate enough to use savings or get into debt to help us get well again.” Read full story Source: The Guardian, 11 September 2022
  9. News Article
    The NHS accused vaginal mesh victims fighting for compensation of lying about pain, it has been claimed. Women suing hospitals over harm they suffered following mesh operations are being subjected to “devastating” treatment, according to Robert Rose, the head of clinical negligence at law firm Lime Solicitors. Campaign group Sling the Mesh, which represents thousands of patients, said it had received reports of those injured claiming they have been told their symptoms are psychosomatic, that their evidence is not convincing because of their mental state, or that they are lying about their pain. It comes as MPs are set to hold an inquiry following up on the Independent Medicines and Medical Devices (IMMD) Safety Review, chaired by Baroness Cumberlege in 2020, which looked into cases of patients being harmed by mesh procedures, sodium valproate, and hormone pregnancy tests. Lady Cumberlege called for the government to launch a redress scheme for patients in order to provide them with financial support without the need for them to go through clinical negligence battles. Lisa, whose name has been changed to protect her identity, launched her claim in 2016, and it was settled this summer when a judge ruled in her favour. Documents shared with The Independent reveal that NHS lawyers argued she was being “dishonest” about her injuries, and presented video surveillance. The judge subsequently ruled that she had not been dishonest. Speaking about her ordeal, Lisa said: “Once they decided that I’d been dishonest, it changed from admitting liability to basically working out pain levels and stuff like that, and I had to prove that I wasn’t being dishonest. It was genuinely the worst thing I’ve ever gone through, ever. There’s not even a word that I can use to describe it, to say how it made me feel. The stress of it was just immense." Read full story Source: The Independent, 11 September 2022 Further reading Doctors shocking comments to women harmed by mesh Specialist mesh centres are failing to offer adequate support to women harmed by mesh (Patient Safety Learning and Sling the Mesh) “There’s no problem with the mesh”: A personal account of the struggle to get vaginal mesh removal surgery
  10. News Article
    A new patient safety chief should be appointed in each of the four UK nations to oversee health and social care and tackle the currently “fragmented and complex” system, experts have urged. The Professional Standards Authority for Health and Social Care (the body that oversees the 10 statutory bodies that regulate health and social care professionals in the UK, including the General Medical Council) has called for what it described as a radical rethink to improve safety in care. In a report published last week, it recommended the appointment of an independent health and social care safety commissioner (or equivalent) for each UK country. These commissioners would identify current and potential risks across the whole health and social care system, it said, and instigate necessary action across organisations. Read full story (paywalled) Source: BMJ, 6 September 2022 Related reading Working together to achieve safer care for all: a blog by Alan Clamp (chief executive of the Professional Standards Authority) Joining up a fragmented landscape: Reflections on the PSA report ‘Safer care for all’ (a blog from Patient Safety Learning
  11. News Article
    NHS trusts will draw on billions of pounds of cash reserves built up during the pandemic to help fund their costs this year, while using aggressive accounting treatments to stop the spending hitting the bottom line. HSJ analysis reveals trusts’ balance sheets are in a far stronger position than before the pandemic, with cash levels reaching around £18bn – three times higher than in March 2020. There have been increasing concerns around the financial outlook for the health service, with funding levels falling in real terms due to spiralling inflation. NHS England has warned of service cuts being needed to balance the accounts, while local leaders have warned of “impossible choices” after being told to deliver “cost improvement plans” of around 5 per cent. However, sources said the strong cash position offers significant headroom to avoid service cuts in the short term, by using the cash reserves built up during covid. But to avoid this impacting on the reported bottom line in the NHS accounts, which would risk a budget breach, they will deploy accounting treatments which reduce reported expenditure. Read full story (paywalled) Source: HSJ, 12 September 2022
  12. Content Article
    Last week the Professional Standards Authority for Health and Social Care (PSA) published a new report, Safer care for all – solutions from professional regulation and beyond, which examines the current state of professional health and care regulation in the UK. In this blog, Patient Safety Learning considers this report from a patient safety perspective.  PSA's chief executive, Alan Clamp, has also written a blog for the hub on the report, which can be read here.
  13. Content Article
    In a recent report, the Professional Standards Authority (PSA) for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care. In this blog, Alan Clamp, PSA's chief executive, summarises these challenges and the possible solutions. You can also read Patient Safety Learning's reflections on the PSA report here.
  14. Content Article
    Listen to Roy Lilley read his daily NHSManagers.net e-Letter. Roy Lilley is a health policy analyst, writer, broadcaster and commentator on the National Health Service and social issues.
  15. Content Article
    In January 2019, not long before the COVID-19 pandemic began, Laurent-Henri Vignaud and Françoise Salvadori published what would turn out to be a very timely book, Antivax: Resistance to Vaccines from the 18th Century to the Present Day. In a recent presentation at the French College of General Medicine's 15th Congress of General Medicine, Vignaud, a historian of science, gave examples from the past to show that opposition to vaccines, which has come to light during the COVID-19 pandemic, is neither a recent phenomenon nor specific to France.
  16. Content Article
    Everybody makes mistakes at work but what if you're a doctor and you ruin a patient's life - or even end it? Doctor-turned-writer Jed Mercurio recalls a catalogue of errors from his years as a medical student.
  17. Content Article
    In a television studio in Stoke-on-Trent last month, Liz Truss and Rishi Sunak traded blows over everything from credit card economics to Channel migrants to the accessories chain Claire’s. The list of issues the pair clashed over was dizzyingly long. There was one glaring omission, however. In the hour-long debate there was not a single mention of the NHS – despite being engulfed in its biggest ever crisis. The NHS now shares the same traits as many of those relying upon it to keep them alive and well: it is elderly, has multiple comorbidities, and is in dire need of emergency care. Summer has left it on its knees. Worse is expected this winter. “The new prime minister will inherit an NHS in its worst state in living memory,” says Matthew Taylor, the chief executive of the NHS Confederation, which represents the healthcare system in England, Wales and Northern Ireland. “There is no escaping that the NHS is in a state of crisis.”
  18. News Article
    The NHS is trialling a fleet of electric vehicles to help relieve pressure on ambulance services while also helping the NHS cut its carbon footprint. The vehicles are part of a £2.1m investment as the NHS becomes the first health service in the world to commit to reaching net zero by 2040, said NHS England, with eight ambulance trusts trialling 21 zero-emission vehicles of various types. Six of these new green vehicles are "dedicated to mental health response in the community", NHS England said. It emphasised that it hoped this development will "cut emergency response times for people with mental health needs and help reduce demand on traditional double-crewed ambulances". The new dedicated mental health response vehicles differ in design from traditional ambulances by having fewer fluorescent markings and a much less clinical interior, to help put patients at ease. However, they still carry the equipment needed to respond to the most serious life-threatening emergencies. NHS England highlighted that the all-electric vehicles can be deployed as a rapid response vehicle when someone is experiencing a mental health crisis, "providing a safe space for healthcare workers to support patients with mental health needs". Claire Murdoch, national director for mental health, NHS England explained that the mental health response vehicles are an important addition to mental health care, and added: "we have a double win of being able to improve the experience of patients in crisis whilst also caring for the planet". Read full story Source: Medscape, 6 September 2022
  19. Content Article
    Brian Edwards, Managing Director of Husoteria Ltd, shares his speaker abstract from the 5th European pharmacovigilance congress held 1-3 December 2021. To view all the speaker abstracts from the congress, published in the Therapeutics Advances in Drug Safety journal, download the attachment below.
  20. Content Article
    Annual NHS Staff Survey results show an average decline in those feeling optimistic about their career within the NHS. One area of concern, in particular, was the amount of NHS workers who felt they were not adequately recognised and rewarded. This poses a threat to the healthcare provider’s People Promise. As part of the NHS’ People Promise, one of the key values include: ‘we are recognised and rewarded. At a time when much of the NHS is suffering from staff shortages, it is vital to find solutions to boost employee morale. Following this report from Each Person, the NHS has highlighted two key areas that need to be addressed to combat staff dissatisfaction: continuing their advocacy for increased investment and support to raise staff numbers; and relieving points of pressure to foster a positive working culture across the organisation. Consequently, NHS trusts have taken positive steps to ensure that their employees feel more appreciated for their hard work through rewards and recognition.
  21. Content Article
    Chief Product Officer Mark Fewster speaks with iTS Leadership’s Judy Walker on transforming your understanding through after action reviews. Digressions include paediatric care in the 90s, ‘Six Blind Men and an Elephant’, and learning to trust others.
  22. News Article
    Liz Truss has been warned against “fantasy predictions” that the NHS can return to normal without radical change and was told that “unacceptable standards” are being normalised. In a rare political intervention, the professional standards body for the UK’s 220,000 doctors agreed that the NHS was routinely letting down patients. The Academy of Medical Royal Colleges said politicians must be prepared for radical changes to save the health service. Closing smaller hospitals, accepting that routine dentistry cannot be free for everyone and a return of Covid volunteers to allow doctors to treat more patients were all suggested by the head of the academy. The academy released a report that declared the NHS was in crisis, writing: “The system is providing increasing proportions of care or services which are sub-standard, threaten patient safety, and should not be acceptable in a country with the resources that we have in the United Kingdom. If we do not act with urgency, we risk permanently normalising the unacceptable standards we now witness daily.” The report sets out a series of recommendations for reform, including boosting staff numbers, reforming social care and spending more on technology. Helen Stokes-Lampard, the academy’s chairwoman, said patients were facing a “dismal winter” and that politicians must take difficult decisions. “If we don’t make changes it will inevitably deteriorate further,” she said. “The demand isn’t going away, the pressure isn’t going away, which is why the challenge for our government and for our whole society is to confront these issues and have a difficult conversation.” Read full story (paywalled) Source: The Times, 9 September 2022
  23. Content Article
    The NHS Confederation, NHS Providers, the Academy of Medical Royal Colleges, National Voices and the Richmond Group of Charities have penned a joint letter to the new Prime Minister warning that without urgent action on key priorities the NHS risks being trapped in a relentless cycle unable to meet rising patient need and demand. The five organisations, which together represent NHS leaders, clinicians and patients, are calling on the new government to take rapid action to address five key priorities in the short term.  These priorities are: Workforce Social care Capital funding  The impact of the cost of living crisis and inflation Strengthening the voice of people living with ill health in decision making.
  24. News Article
    There is a "toxic" culture of bullying and blame in the Isle of Man's emergency department at Noble's Hospital, an inspection has found. The Care Quality Commission's report said it was a "significant concern" along with "ineffective" staff training and medicine storage systems. It found a "significant disconnect" between nursing and medical staff had the potential to "cause or contribute to patient harm". During inspectors' four-day visit in June, some staff said the attitude and behaviour of senior medics was "feral". Manx Care's director of nursing Paul Moore said the understaffed department had been "really struggling" at times. He warned efforts to change governance and culture would take time. Mr Moore said on average the emergency department had about 50% of the required staff over a given month, and recruitment was the "number one priority" to help make lasting changes. "The bottom line is I have to put staff in front of patients before other considerations, especially when we're short", he added. Read full story Source: BBC News, 8 September 2022
  25. News Article
    NICE has rubber-stamped guidance on self-harm that said GPs should ‘regularly review’ patients and offer a ‘specific CBT intervention’. The guidance is the first to be drawn up in 11 years and emphasises the importance of referring patients to specialist mental health services but stresses that, for patients who are treated in primary care, continuity is crucial. The final guideline mirrors the draft guidance in advising that self-harming patients, when treated in primary care, must receive: regular follow-up appointments; regular reviews of self-harm behaviour; a regular medicines review. GPs must also provide care for co-existing mental health issues, including referral to mental health services where appropriate, as well as information, social care, voluntary and non-NHS sector support and self-help resources, it said. The guidance said that referring people to mental health services would ‘ensure people are in the most appropriate setting’. Read full story Source: Pulse, 8 September 2022
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