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Patient Safety Learning

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  1. Content Article
    Health systems currently present a great degree of complexity, which provides risks to patients related to healthcare, and the possibility of incidents with or without harm. Patient safety culture highlights the need to investigate, analyse, and mitigate incidents to reduce risks to the patient. Medication errors have a high potential to do harm in paediatric hospital routines and most of them are preventable. The objective of this study was to describe a severe drug-related adverse event and present the root cause analysis and implemented improvements.
  2. Content Article
    In basic terms, a safety management system (SMS) is a formal arrangement for managing, assuring, and improving safety. An SMS is not a single document, it is a framework for managing all risks that arise from running a transport system. It defines roles and responsibilities, sets arrangements for safety mechanisms, involves workers in the process, and ensures continuous improvement. The Railways and Other Guided Transport Systems (Safety) Regulations 2006 (ROGS) introduced the requirement for and content of an SMS. The regulations require most railway operators to maintain an SMS, and hold a safety certificate or authorisation indicating that the SMS has been accepted by the Office of Rail and Road.
  3. Content Article
    The objective of a Safety Management System is to provide a structured management approach to control safety risks in operations. Effective safety management must take into account the organisation’s specific structures and processes related to safety of operations.
  4. Content Article
    The Resilient Health Care Society (RHCS) is a non-profit organisation registered in Sweden. The goal of the Society is to provide an international forum for coordination and exchange of principles, practices, and experiences, by bringing together researchers and professionals working with or interested in Resilient Health Care. Research and practice in Resilient Health Care aims to develop and promote practical solutions, based on a solid scientific foundation, to ensure that health care systems can perform as intended under expected and unexpected conditions alike. Links to some of their publications can be found below.
  5. News Article
    A 90-year-old woman waited 40 hours for an ambulance after a serious fall. Stephen Syms said his mother, from Cornwall, fell on Sunday evening and an ambulance arrived on Tuesday afternoon. She was then in the vehicle for 20 hours at the Royal Cornwall Hospital. It comes as an ambulance trust warns lives are at risk because of delays in patient handovers. It was also reported a man, 87, who fell, was left under a makeshift shelter waiting for an ambulance. South Western Ambulance Service said it was "sorry and upset" at the woman's wait for an ambulance. Mr Syms, from St Stephen, told BBC Radio Cornwall: "We are literally heartbroken to see a 90-year-old woman in such distress, waiting and not knowing if she had broken anything. "The system is totally broken." He said it took nine minutes before his 999 call was answered. "If that was a cardiac arrest, nine minutes is much too long, it's the end of somebody's life," he said. Mr Syms said paramedics were "absolutely incredible people". He added: "The system is not deteriorating, it's totally broken and needs to be urgently reviewed." Read full story Source: BBC News, 19 August 2022
  6. News Article
    All patients should be able to choose the hospital with the shortest waiting times, a former health secretary has said. Alan Milburn, the Labour health secretary under Tony Blair from 1999 to 2003, called for urgent reforms and warned that the NHS was “close to breaking point” and “in the worst state I have ever seen”. A record 6.7 million people are now on waiting lists, with the numbers waiting in Accident and Emergency departments for at least 12 hours surging by more than a third in a month. Writing for The Telegraph, Mr Milburn called for urgent reforms to give patients more choice and control while preventing a “tsunami” of chronic diseases fuelled by unhealthy lifestyles. In recent months, ministers have promised that those facing the longest waits will be offered treatment further away and offered travel and accommodation costs, but only around 140 patients were booked in for such surgery by June. Mr Milburn called for the option to be offered to all patients, urging health officials to use the NHS app as a way for people to chose the hospital with the shortest wait. So far, officials have promised to ensure that the app allows patients to check the average waiting time at their local hospital for their condition and compare it with others. Read full story (paywalled) Source: The Telegraph, 17 August 2022
  7. News Article
    Almost a third of acute trusts have been identified by NHS England as being ‘at risk’ of missing key targets for electives and cancer recovery, with some facing “periodic calls between ministers and CEOs”, HSJ can reveal. NHS England has identified 39 acute trusts at the most risk of missing the targets of having no patients waiting 78 weeks or more for elective treatment by April 2023, and returning the 62-day cancer waiting list to pre-pandemic levels by March 2023. HSJ can reveal the full lists of 19 trusts placed in “tier one” – the most at-risk category – and 20 in “tier two” (see lists below). The “at risk” trusts represent 31% of the acute providers in England, with many of them among the lowest performers in the country for elective and cancer recovery. Read full story (paywalled) Source: HSJ, 19 August 2022
  8. Content Article
    Covid-19 has posed a huge challenge to the delivery of safe care, both when infection rates were at their highest levels and in terms of its long-term impact on health and social care systems.[1] The pandemic has magnified existing patient safety issues, created new ones, and exposed safety gaps which require systemic responses. This month the World Health Organization (WHO) has published a new report, Implications of the Covid-19 pandemic for patient safety: A rapid review.[2] The review aims to create a greater understanding of the impact of the pandemic on patient safety, particularly in relation to diagnostic services, treatment and care management. In this blog, Patient Safety Learning, one of the international organisations who contributed to this review, provides an overview and reflections on some the key themes and issues raised in this review.
  9. News Article
    Britain is in the grip of a new silent health crisis. For 14 of the past 15 weeks, England and Wales have averaged around 1,000 extra deaths each week, none of which are due to Covid. If the current trajectory continues, the number of non-Covid excess deaths will soon outstrip deaths from the virus this year. Experts believe decisions taken by the Government in the earliest stages of the pandemic – policies that kept people indoors, scared them away from hospitals and deprived them of treatment and primary care – are finally taking their toll. Prof Robert Dingwall, of Nottingham Trent University, a former government adviser during the pandemic, said: “The picture seems very consistent with what some of us were suggesting from the beginning. “We are beginning to see the deaths that result from delay and deferment of treatment for other conditions, like cancer and heart disease, and from those associated with poverty and deprivation. “These come through more slowly – if cancer is not treated promptly, patients don't die immediately but do die in greater numbers more quickly than would otherwise be the case.” Read full story (paywalled) Source: The Telegraph, 18 August 2022
  10. News Article
    Dentists in the UK should be encouraged to give antibiotics to patients at high risk of life-threatening heart infection before invasive procedures, a study has found. Research suggests bacteria from the mouth entering the bloodstream during dental treatment could explain 30% to 40% of infective endocarditis cases. The rare but life-threatening condition occurs when the inner lining of the heart chambers and valves become infected. Antibiotics could limit the number of cases and reduce the risk of heart failure, stroke and premature death in high-risk patients, the study says. Current guidelines from the National Institute for Health and Care Excellence (Nice) advise against the routine use of antibiotics before invasive dental procedures for those at risk of infective endocarditis. “Ours is the largest study to show a significant association between invasive dental procedures and infective endocarditis, particularly for extraction and surgical procedures,” said Prof Martin Thornhill from the University of Sheffield, who led the study. Nice should review its guidelines advising against antibiotic prophylaxis, the researchers said. Read full story Source: The Guardian, 19 August 2022
  11. News Article
    Five East Midlands trusts are working with the country’s largest independent mental health provider in a bid to improve service quality, amid concerns patient safety would have been put at risk if they had not stepped in. This move follows the Care Quality Commission (CQC) placing conditions on the registration of St Andrew’s Healthcare in Northampton in July and August last year after inspectors found patients were not given appropriate care in a safe environment. The service could not admit any new patients into forensic, long-stay rehabilitation wards and the wards for people with a learning disability at the women’s service and to the wards for people with a learning difficulty at the men’s service, without consent from CQC following the inspection report. This restriction was lifted in May this year. Following the inspection, five local community and mental health trusts have “buddied up” to provide “targeted support” to improve the care quality provided by the charity provider. The programme is being co-ordinated by Northamptonshire Healthcare Foundation Trust. Angela Hillery, chief executive of NHFT and Leicestershire Partnership Trust, told HSJ there was an “overwhelming” agreement amongst the pre-existing East Midlands alliance of trusts that they should work with St Andrew’s, which “clearly had an improvement journey to make”. Ms Hillery said: “If we were not going to help, the risk was to our patients. [The initiative] was driven from us to say, ‘these are our patients and why wouldn’t we want to support each other as I know St Andrew’s would support us in the same situation.” Read full story (paywalled) Source: HSJ, 18 August 2022
  12. News Article
    Questions are being asked why the government is sticking to its cap on medical and dentistry places. A shortage of doctors and other medical staff has been described as the biggest challenge facing the NHS. But the number of places at UK medical schools are capped - in England this year there are 7,500 places. England's Education Secretary James Cleverly told the BBC that you can't just "flick a switch" to increase the capacity to train more doctors. Medicine is one of a handful of courses where numbers are limited by the government, because the cost is heavily subsidised. In 2020 and 2021 the government lifted the cap on numbers, which last year led to more than 10,000 places being accepted. But this year the cap in England is being reintroduced. Mr Cleverly told the BBC that the nature of highly technical, vocational courses like medicine meant increasing the number of places was far from straightforward. "To increase those numbers you would also need to increase the capacity in training institutions, both in universities and in hospitals. "It is not something you can just flick a switch and significantly increase the capacity to train. "The increases have got to be funded, they are technical and expensive courses and we need to understand the balance of requirements between these courses and other courses that the government is supporting financially." Read full story Source: BBC News, 18 August 2022
  13. News Article
    A grieving family has welcomed new guidance to try to prevent a common surgical procedure from going wrong and causing deaths. Oesophageal intubation occurs when a breathing tube is placed into the oesophagus, the tube leading to the stomach, instead of the trachea, the tube leading to the windpipe. It can lead to brain damage or death if not spotted promptly. Glenda Logsdail died at Milton Keynes University Hospital in 2020 after a breathing tube was accidentally inserted into her oesophagus. The 60-year-old radiographer was being prepared for an appendicitis operation when the error occurred. Her family welcomed the guidance, saying in a statement: “We miss her terribly but we know that she’d be happy that something good will come from her tragic death and that nobody else will go through what we’ve had to go through as a family." Oesophageal intubation can occur for a number of reasons including technical difficulties, clinician inexperience, movement of the tube or “distorted anatomy”. The mistake is relatively common but usually detected quickly with no resulting harm. The new guidance, published in the journal Anaesthesia, recommends that exhaled carbon dioxide monitoring and pulse oximetry – which measures oxygen levels in the blood – should be available and used for all procedures that require a breathing tube. Experts from the UK and Australia also recommended the use of a video-laryngoscope – an intubation device fitted with a video camera to improve the view – when a breathing tube is being inserted. Read full story Source: The Independent,18 August 2022
  14. Content Article
    Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.
  15. News Article
    The midwife leading a review into Nottingham's maternity services has urged families and staff to come forward with their experiences. Donna Ockenden was appointed in May to head the inquiry into the services at Queen's Medical Centre and City Hospital. It was launched after more than 100 families with experiences of maternity failings wrote to former Health Secretary Sajid Javid demanding the action. A much-criticised initial review was subsequently scrapped. Ms Ockenden, who uncovered 200 avoidable baby deaths at Shrewsbury and Telford NHS Trust across two decades, said the review is now open to families, NHS workers and others who wish to contribute. "By September 1 we'll be ready to receive contact from families," she told Nottinghamshire Live. "In the mean time if there are either families or members of the NHS that want to get in touch they can use our new email. And also those who represent communities, whether that's safe communities or women's groups in Nottingham." People can contact the review through the email nottsreview@donnaockenden.com, which was launched last week. Ms Ockenden said that positive steps were being made in putting in place the "building blocks" for the review, which is due to start on 1 September 2022. Read full story Source: Nottinghamshire Live, 17 August 2022
  16. News Article
    The Joint Commission Resources (JCR) has announced the appointment of two world-class and leading healthcare experts to serve as international outside directors on its board of directors: Abdulelah M. Alhawsawi and Sangita Reddy. As international outside directors, Dr. Alhawsawi and Ms. Reddy will provide their global expertise and direction to improve safety and quality of healthcare in the United States and abroad. They will be full voting members of the 13-person board of directors, which serves as JCR’s governing body. The board includes healthcare professionals, business executives and quality experts from around the world. “Dr. Alhawsawi and Ms. Reddy have dedicated their lives to transforming healthcare globally, and we are thrilled to welcome them to Joint Commission Resources’ Board of Directors,” says Jonathan B. Perlin, president and chief executive officer, The Joint Commission. “These board appointments bring unique international expertise and perspective on healthcare policy and the challenges and opportunities to advance quality and safety worldwide.” “We are so pleased that Dr. Alhawsawi and Ms. Reddy are joining Joint Commission Resources’ Board of Directors,” says Jean Courtney, interim president and chief executive officer, and chief operating officer, JCR. “They each bring in-depth and unparalleled international healthcare expertise. This will be invaluable as JCR continues to expand its mission to improve patient safety and quality of care around the globe.” Read full story Source: Joint Commission Resources, 16 August 2022
  17. Content Article
    Stroke is a serious life-threatening medical condition that occurs when the blood supply to part of the brain is cut off. It is the fourth largest cause of death and the leading cause of disability, with almost two thirds of stroke survivors leaving hospital with a disability in the UK.
  18. Content Article
    NHS Resolution received 172 claims relating to anti-infective medications between 1 April 2015 until 31 March 2020. Anti-infective medications include antibiotics, antivirals and antifungals. The analysis in this leaflet focuses on closed claims that have been settled with damages paid and concern an element of the prescribing process: prescribing, transcribing, dispensing, administering and monitoring. Claims concerning a failure to recognise that an anti-infective was indicated have not been included within the analysis.
  19. News Article
    At 34 years old, Dawn Jaxson had two young daughters. Since going through childbirth she had been experiencing a prolapsed bladder and urinary incontinence. Her doctors recommended she have a vaginal mesh fitted to treat the problem, and she didn’t question their advice. But more than 15 years later, she wishes she had. “As soon as I’d actually had it fitted, I felt discomfort,” says Jaxson, now 50. “Then the pain just didn’t go.” After years of almost constant pelvic pain and “countless” medical appointments, Jaxson says: “This little tiny piece of tape is still ruining my life.” “I can literally be sat down and then out of nowhere, it will be like somebody is shoving a red-hot poker through my bladder,” she tells iNews. “Being intimate with somebody is just impossible. Sex is no joy. Imagine your worst period pain you could possibly have, and that’s what it’s like on a daily basis.” NHS Digital records show that between April 2008 and March 2017, 100,516 patients had a tape insertion procedure for stress urinary incontinence. A further 27,016 patients had a mesh procedure for pelvic organ prolapse. But the surgery was suspended in Scotland in 2014 and across the rest of the UK by 2018 following complaints about complications – and a review ordered. The review panel, overseen by Baroness Julia Cumberlege, spoke to more than 700 affected individuals and concluded that pelvic mesh procedures had caused “anguish, suffering, and many ruined lives”. In 2020, the panel set out nine recommendations to help the thousands of women affected, including the creation of specialist centres, so patients could have their mesh removed or receive further treatment. But two years on from that landmark report, women say they are still suffering debilitating symptoms and struggling to access the help they so desperately need. Kath Sansom, the founder of the campaigning group Sling the Mesh, has heard many similar stories from among the group’s 9,700 members. “The lack of action on financial redress is the biggest disappointment for women,” she says. “Pelvic mesh caused lifelong damage, and worse, the majority of us were not given any information on the risks. It’s not our fault this happened to us." “Some women have been left disabled in wheelchairs or walking with sticks. Others have had organs removed where mesh has turned brittle and sliced into them. Seven in 10 have lost their sex life. Everyone suffers chronic pain in varying degrees. Women have lost jobs, marriages, homes, and their quality of life.” Read full story Source: iNews, 18 August 2022
  20. Event
    until
    Join the Health Tech Alliance and Becton Dickinson for a deep dive into the role of technology in improving patient safety. With the evolution of virtual wards and ever-increasing use of technology across the NHS The Health Tech Alliance and Becton Dickinson (BD) are joining forces to deep dive into the role of technology in improving patient safety. The event will be made up of a combination of interactive workshops, plenary sessions, and a panel discussion as well as networking opportunities over lunch and eventing reception. Register
  21. News Article
    Two years after having Covid-19, diagnoses of brain fog, dementia and epilepsy are more common than after other respiratory infections, a study by the University of Oxford suggests. But anxiety and depression are no more likely in adults or children two years on, the research found. More research is needed to understand how and why Covid could lead to other conditions. This study looked at the risks of 14 different disorders in 1.25 million patients two years on from Covid, mostly in the US. It then compared them with a closely-matched group of 1.25 million people who had a different respiratory infection. In the group who had Covid, after two years, there were more new cases of: dementia, stroke and brain fog in adults aged over 65 brain fog in adults aged 18-64 epilepsy and psychotic disorders in children, although the overall risks were small. Some disorders became less common two years after Covid, including: anxiety and depression in children and adults psychotic disorders in adults. The increased risk of depression and anxiety in adults lasts less than two months before returning to normal levels, the research found. Read full story Source BBC News, 18 August 2022
  22. Content Article
    COVID-19 is associated with increased risks of neurological and psychiatric sequelae in the weeks and months thereafter. How long these risks remain, whether they affect children and adults similarly, and whether SARS-CoV-2 variants differ in their risk profiles remains unclear. This study from Taquet et al. looked at the risks of 14 different disorders in 1.25 million patients two years on from Covid, mostly in the US. It then compared them with a closely-matched group of 1.25 million people who had a different respiratory infection. In the group who had Covid, after two years, there were more new cases of dementia, stroke and brain fog in adults aged over 65; brain fog in adults aged 18-64; and epilepsy and psychotic disorders in children, although the overall risks were small. Some disorders became less common two years after Covid, including anxiety and depression in children and adults and psychotic disorders in adults. The increased risk of depression and anxiety in adults lasts less than two months before returning to normal levels, the research found.
  23. News Article
    There is an urgent need to develop evidence based clinical guidelines for managing cases of monkeypox, scientists said, after finding that existing guidance frequently lacked detail and was based on poor research. They urged establishing a 'living guideline' for infectious disease to ensure that up-to-date information, based on robust research, was available globally and in any setting. The study, published in BMJ Global Health, also called for investment to back research into optimal treatments and prophylaxis strategies. The study authors wrote: "The lack of clarity between guidelines creates uncertainty for clinicians treating patients with MPX [monkeypox] which may impact patient care." They concluded: "Our study highlights a need for a rigorous framework for producing guidelines ahead of epidemics and a recognised platform for rapidly reviewing and updating guidance during outbreaks, as new evidence emerges." Current global concern over the spread of monkeypox was an opportune time to act, they argued. Read full story Source: Medscape, 17 August 2022
  24. News Article
    The Irish health services did “relatively well” during Covid-19 but, as in other countries, the pandemic unmasked existing problems, a renowned patient safety expert has said. Peter Lachman of the Royal College of Physicians of Ireland (RCPI), was one of nine international experts who consulted on a new World Health Organization (WHO) report on the implications of the Covid-19 pandemic for patient safety. Dr Lachman said the impact is only starting to be understood. “Ireland did very well early on [in the pandemic], then opened up over Christmas [2020] which led to our numbers going sky-high, then we clamped down again,” he said. "We did well on some things and not so well on others. We have done relatively well when compared with other countries." “Covid-19 was an event which around the world unmasked problems which were there already rather than creating them necessarily,” he said. “The findings start with safety problems — we’ve had safety problems in Ireland but things are getting better. There is a good strategy coming on. I’ve worked with hospitals around the country on this. It’s no worse than other countries.” Read full story Source: The Irish Examiner, 12 August 2022
  25. News Article
    Doctors and health service providers welcomed publication of an NHS strategy for managing demand ahead of another busy winter for health and social care, but said it failed to address underlying problems with the system. In a letter to the heads of NHS trusts and integrated care boards, NHS England chiefs said they had begun planning for capacity and operational resilience in urgent and emergency care ahead of "significant challenges" during the coming months. The British Medical Association (BMA) said the strategy was a "step in the right direction", but "lacks detail", while the Royal College of Emergency Medicine (RCEM) said it amounted to little more than "a crisis mitigation plan". The package of measures included creating the equivalent of 7000 extra general and acute beds through a mix of new physical beds, scaling up 'virtual' beds, and "improvements in discharge and flow". The letter acknowledged that there was "a significant number of patients spending longer in hospital than they need to" and that whilst "the provision of social care falls outside of the NHS’s remit, the health service must ensure patients not requiring onwards care are discharged as soon as they are ready and can access services they may need following a hospital stay." Read full story Source: Medscape, 15 August 2022
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