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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Birthrights are receiving an increasing number of enquiries regarding restrictions of maternity services due to the staffing crisis, including closure of midwifery-led units and homebirth services. In order to get a full picture, including a regional overview, Birthrights would like to know if your local maternity service has been restricted in any way. To help gather evidence, Birthrights are calling for anyone who knows what the current situation is at their local Trust, including whether staffing is leading to: Their homebirth service being restricted. Their Midwife-Led Unit being closed. To take part follow the link below.
  2. Event
    When accidents occur in healthcare, providers and health systems have an urgent responsibility to respond to prevent future harm. In this online course from the Institute for Healthcare Improvement (IHI), you'll learn to improve your event review process with a unique approach — endorsed by leaders in patient safety across the United States and abroad — that expands upon traditional root cause analysis. Moving swiftly after a safety incident occurs, you'll learn to establish a small team to conduct interviews, develop a flowchart, and pinpoint vulnerabilities in your system: poor equipment design, inadequate training, or insufficient resources. Most importantly, by the end of the course, you'll gain tools and strategies to address these vulnerabilities with sustainable actions that really work to prevent future harm. This is the focus of Root Cause Analyses and Actions — or RCA2. During this online course, you will: Explore the type of culture it takes to support RCA2. Learn to prioritize events for RCA2 review. Assemble an effective RCA2 team. Explore strategies to engage patients in the RCA2 process. Gain tools and techniques for conducting interviews after an adverse event occurs. Use flowcharting after an adverse event to understand what happened and why. Learn to identify actions that will protect patients and staff from future harm. Apply goal-setting and measurement techniques to facilitate sustained improvement. Implement approaches for evaluating the success of RCA2. Explore creative possibilities for future applications of RCA2.
  3. News Article
    Department of Health and Social Care (DHSC) officials are concerned that many more people are dying than expected in recent months – particularly older working-age people – with NHS care delays and interruptions a likely cause. HSJ understands there is concern and analysis under way across the chief medical officer’s team and in the Office for Health Improvement and Disparities. The DHSC told HSJ initial work showed the biggest causes of the “excess deaths” were cardiovascular disease (heart attacks and strokes) and diabetes. This supports the case they are being caused by a combination of the current very long delays for ambulances and other emergency care, and by people with heart disease and diabetes missing out on routine checks due to Covid and its knock-on effects, HSJ was told. Read full story (paywalled) Source: HSJ, 17 August 2022
  4. News Article
    Dozens of referrals to specialist care for women with serious mental health problems during or after pregnancy are being turned down because no bed was available, data collected by HSJ reveals. HSJ submitted freedom of information requests to 19 trusts running mother and baby units (MBUs) – which are inpatient services where women who experience serious mental health problems during or after pregnancy can stay with their child – asking for the “total number of referrals… which could not be admitted because no bed was available”. Although all of the 19 trusts HSJ sent freedom of information requests to responded, many said they did not hold this information. However, five – Cumbria, Northumberland, Tyne and Wear Foundation Trust, Essex Partnership University FT, Greater Manchester Mental Health FT, Hertfordshire Partnership University FT, and Nottinghamshire Healthcare FT – together identified 197 referrals which were rejected. Greater Manchester identified a further three which were turned down in the calendar year 2022, although it did not specify which financial year this was. Several experts told HSJ the figures reflected a lack of capacity for mothers with serious mental health problems. Maternal Mental Health Alliance campaign manager Karen Middleton said MBUs offered “the best outcomes” for new mothers who needed inpatient treatment". Ms Middleton continued: “When a much-needed MBU bed isn’t available, women instead face admission to general adult psychiatric wards, separating them from their newborn babies at a crucially important time for relationship development. These wards lack appropriate facilities and expertise to support postnatal mothers with their specific physical and emotional needs.” Read full story (paywalled) Source: HSJ, 16 August 2022
  5. Content Article
    Monthly publications from the Joint Commission that outlines an incident, topic or trend in healthcare that could compromise patient safety.
  6. News Article
    Senior doctors have raised concerns about the numbers of patients now dying in their A&E department due to extreme operational pressures. HSJ has seen an internal memo sent to staff at Royal Albert Edward Infirmary in Wigan, which warns it is becoming “increasingly common” for patients to die in the accident and emergency department. The memo suggests the department has reported five deaths in the latest weekly audit, when it would normally report one or two fatalities. The memo said: “Of the 72 patients in A&E as I write this, 16 have been there over 24 hours and 34 over 12 hours. The longest stay is almost 48 hours… “It’s becoming increasingly common to die in A&E. We have included A&E deaths [in weekly audits] for the last 4 years. They used to be 1 or 2. This week there were 5. They used to die at or just after arrival, but that’s changing too… “There is every reason to think winter will be worse.” The memo echoes warnings made by numerous NHS leaders in recent months around the intense service pressures and an increased risk of incidents and mistakes. Read full story (paywalled) Source: HSJ, 17 August 2022
  7. News Article
    The number of midwives has fallen in every English region in the past year, figures show. Numbers dropped by around 600 on top of a longstanding shortage of more than 2000 midwives, according to analysis of NHS Digital data by the Royal College of Midwives (RCM). The RCM said more investment is needed in maternity services to ensure the safety and quality of care, as "even the smallest falls are putting increasing pressures on services already struggling with shortages, worsened by the pandemic". Dr Suzanne Tyler of the RCM said midwife numbers had "fallen significantly over the past year on top of already serious shortages" in England. Dr Tyler said: "The falls across the regions are compounding the difficulties employers are facing to recruit and keep their midwives. "We are raising these issues because we want women to get the best possible care and midwives to not only stay in the profession, but to encourage others to become one. "These figures must shock this moribund Government into action for the sake of women, babies, their families and staff." Read full story Source: Medscape, 16 August 2022
  8. News Article
    Survivors of the contaminated blood scandal have been awarded interim government payments after a 40-year battle, but thousands of parents and children of the victims have still received nothing. Ministers have accepted the urgency of the need to make the £100,000 payments to about 3,000 surviving victims, after being warned that those mistakenly infected with HIV and hepatitis C were dying at the rate of one every four days. But parents and children of the victims accused the government of perpetuating the scandal by failing to recognise their own trauma and loss in today’s announcement. Contaminated blood products administered in the 1970s and 1980s to up to 6,000 people have already led to the deaths of more than 2,400 people in the biggest treatment scandal in NHS history. The government said it intends to make payments to those who have been infected and bereaved partners in England by the end of October. The same payments will be made in Scotland, Wales and Northern Ireland. Announcing the plan, the prime minister, Boris Johnson, said: “While nothing can make up for the pain and suffering endured by those affected by this tragic injustice, we are taking action to do right by victims and those who have tragically lost their partners by making sure they receive these interim payments as quickly as possible. “We will continue to stand by all those impacted by this horrific tragedy, and I want to personally pay tribute to all those who have so determinedly fought for justice.” Read full story Source: The Guardian, 17 August 2022
  9. News Article
    Only a quarter of patients on valproate, who do not have appropriate contraception, are being referred by their pharmacist to their GP or a specialist about the issue, an audit carried out by NHS England has found. A report on the 2019/2020 Pharmacy Quality Scheme Valproate Audit — which was carried out in community pharmacies across England — published on 11 August 2022, has indicated that the Medicines and Healthcare products Regulatory Agency’s (MHRA’s) safety requirements for use of valproate in women and girls of childbearing age, and trans men who are biologically able to be pregnant, are “still not being fully met”. Since 2018, the MHRA has advised that valproate, a treatment for epilepsy and bipolar disorder, must not be used in anyone of childbearing potential, unless a Pregnancy Prevention Plan (PPP) is in place. As part of a PPP, pharmacists are required to remind patients of the risks of taking sodium valproate in pregnancy and the need for highly effective contraception; ensure patients have been given the patient guide; and remind patients of the need for an annual specialist review. However, the audit, which was conducted by 10,293 community pharmacies in England, including responses from 12,068 patients and patient representatives, found that pharmacists were not referring or signposting “a sizeable minority”, who appeared to be without appropriate contraception, back to the prescriber. The report said that community pharmacists should refer “all people aged 12–55 who are biologically able to be pregnant and have not had their valproate medication reviewed within the last 12 months to their GP or specialist, as well as to local contraception services as appropriate”. For patients not referred to their GP or specialist, the report said that the pharmacist should be able to confirm that the patient is fully informed, understands the risks of not using highly effective contraception and knows who to contact if their circumstances change. Read full story Source: The Pharmaceutical Journal, 12 August 2022
  10. News Article
    A 60-year-old woman in England’s poorest areas typically has the same level of illness as a woman 16 years older in the richest areas, a study into health inequalities has found. The Health Foundation found a similarly stark, though less wide, gap in men’s health. At 60 a man living in the most deprived 10% of the country typically has the burden of ill-health experienced by a counterpart in the wealthiest 10% at the age of 70. The thinktank’s analysis of NHS data also shows that women in England’s poorest places are diagnosed with a long-term illness at the age of 40 on average, whereas that does not happen to those in the most prosperous places until 48. The findings underline Britain’s wide and entrenched socio-economic inequalities in health, which the Covid-19 pandemic highlighted. Ministers have promised to make tackling them a priority as part of the commitment to levelling up, but a promised white paper on that has been delayed. Researchers led by Toby Watt said their findings were likely to be the most accurate published so far because they were based on data detailing patients’ interactions with primary care and hospital services, and unlike previous studies did not rely on people’s self-reported health. “In human terms, these stark disparities show that at the age of 40, the average woman living in the poorest areas in England is already being treated for her first long-term illness. This condition means discomfort, a worse quality of life and additional visits to the GP, medication or hospital, depending on what it is. At the other end of the spectrum, the average 40-year-old woman will live a further eight years – about 10% of her life – without diminished quality of life through illness,” Watt said. Read full story Source: The Guardian, 17 August 2022
  11. Content Article
    Welcome to the being better together podcast, from Learning from Excellence and Civility Saves Lives. This podcast from Learning from Excellence and Civility Saves Lives is a series of conversations with people who inspire us, about making healthcare a better place to work. It covers a wealth of topics, from workplace cultures, through inspiration, laughter and joy, to appreciative inquiry and how do work safely.
  12. Content Article
    NHS England has published the new Patient Safety Incident Response Framework (PSIRF). Dr Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England, and Aidan Fowler, National Director of Patient Safety and Deputy Chief Medical Office at NHS England/DHSC, discuss the new framework, the preparation behind it, and how they see PSIRF fundamentally changing the NHS’s approach to patient safety incident response, supporting learning, improvement and compassion, to make care safer for our patients.
  13. Content Article
    Non-communicable illness is responsible for 88% of the burden of disease in England, with the majority falling most heavily on the poorest in society. The COVID-19 pandemic has highlighted pervasive socioeconomic, ethnic and geographical health inequalities in our society. But quantifying health inequalities can be difficult due to the complexities of comparing people with multiple different long-term conditions (multimorbidity) and assessing the implications for their health care needs. In this analysis from the The Health Foundation, a novel tool known as the Cambridge Multimorbidity Score was used to assess the relative impact of different patterns of diagnosed illness on people and their use of the health care system. 
  14. Content Article
    Pancreatic Cancer UK has produced this infographic on recognising the symptoms of pancreatic cancer.
  15. Content Article
    Picker, an international charity working across health and social care, have published the results of their National Cancer Patient Experience Survey. Almost 60,000 people responded to the survey, which was coordinated by Picker on behalf of NHS England and conducted between October 2021 and February 2022. The survey included people aged 16 years and over with a confirmed primary diagnosis of cancer and who had been treated in hospital between April and June 2021.
  16. Content Article
    An HSJ roundtable, supported by Edwards Lifesciences, looked at how trusts can find solutions to the complex challenges of improving patient safety in operating theatres and intensive care units. 
  17. Content Article
    The European Network for Safer Healthcare (ENSH) joined forces with the European Association of Urology Nurses (EAUN) to work on a policy campaign to prevent catheter-associated urinary tract infections (CAUTI) in Europe as a path to improving patient safety and preventing anti-microbial resistance (AMR) through: Improvement of adherence to existing European guidelines to prevent CAUTI. Development of European indicators to support the European Centre for Disease Prevention and Control (ECDC) and/or national surveillance systems.
  18. Content Article
    Historical and current methodologies in patient safety are based on a deficit-based model, defining safety as the absence of harm. This model is aligned with the human innate negativity bias and the general philosophy of health care: to diagnose and cure illness and to relieve suffering. While this approach has underpinned measurable progress in healthcare outcomes, a common narrative in the healthcare literature indicates that this progress is stalling or slowing. It is important to learn from and improve poor outcomes, but the deficit-based approach has some theoretical limitations.
  19. Event
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    This FDA/PQRI Workshop will bring together leaders from regulatory agencies, industry, and academia to discuss critical topics in distributed manufacturing and point of care manufacturing. Further information
  20. Event
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    The Europe Forum will follow the established model of the CMC Forum series with focus on topics and regulatory updates relevant for Europe. The Forum strives to share information with the regulatory agencies to assist them in merging good scientific and regulatory practices. Register
  21. Content Article
    Here are some useful projects that NHS East London teams from each directorate took part in as part of demonstrating what they have learned from Cohort 3 of the Enjoying Work Learning System.
  22. News Article
    Thirty-four hospital buildings in England have roofs made of concrete that is so unstable they could fall down at any time, ministers have admitted. The revelation has prompted renewed fears that ceilings at the hospitals affected might suddenly collapse, injuring staff and patients, and calls for urgent action to tackle the problem. Maria Caulfield, a health minister, made the disclosure in a written answer to a parliamentary question asked by the Liberal Democrats’ health spokesperson, Daisy Cooper. Caulfield said surveys carried out by the NHS found that 34 buildings at 16 different health trusts contained reinforced autoclaved aerated concrete (RAAC), which one hospital boss has likened to a “chocolate Aero bar”. RAAC was widely used in building hospitals and schools in the 1960s, 70s and 80s but has a 30-year lifespan and is now causing serious problems. In 2020 Simon Corben, NHS England’s director of estates, declared that RAAC planks posed a “significant safety risk” because their age meant they could fall down without warning. Read full story Source: The Guardian, 14 August 2022
  23. News Article
    Lamborghinis and ski trips to the Swiss Alps were among the incentives a pharmaceutical giant developed to market a surgical device that has ruined the lives of hundreds of Australian women. Documents obtained by the ABC show the extent to which Johnson and Johnson oversold its surgical mesh products, which are used to treat incontinence and prolapse after childbirth. They paint a picture of a company that tried to sell surgeons a jet-setting lifestyle where they could insert four devices "before lunch" and notch up $10,000 in surgeries in a single morning. The mesh devices have left at least 3,000 Australian women with serious side effects including chronic pain, infections and inability to have sex, and are the subject of both a Senate inquiry and a class action. New court documents released in the class action against Johnson and Johnson show that as early as 2009, concerns were raised inside the company that it was making "a huge mistake" by commercialising its latest brand of mesh, was "rushing to market", and opening up the use of the product to "unqualified surgeons". Lawyers from Shine, who are representing the women in the class action, claim the pharmaceutical giant did not investigate proper clinical trials on the possible complications of the mesh. Read full story Source: ABC News, 13 August 2022
  24. News Article
    Redeployment of community staff to other services – meaning visits for babies and parents were missed – was the “wrong decision” and would “never be repeated”, a provider has stated. Nikki Lawrence, the head of public health nursing at Sirona Care and Health, which provides community services for Bristol and the surrounding area, appeared to blame the government for about 70% of its health visiting staff being redeployed to adult services, leaving around 30% to care for new families at the height of the pandemic. Health visitors take over from midwives to monitor the health of children and parents for a period after the baby is born, including to guard against safeguarding threats. Ms Lawrence said: “The national learning about redeployment – we have reflected on it, the government has reflected on it and they have agreed it was the wrong decision to make. “We basically abandoned families at a time of need, and that decision will never, ever be taken again, from what I’ve been told. In hindsight it was the wrong decision to make, and… it did have a detrimental impact on families and we really regret that, but it was out of our hands.” Read full story (paywalled) Source: HSJ, 16 August 2022
  25. News Article
    As the risk of cyberattacks on medical devices continues to mount, the Food and Drug Administration isn’t doing enough to ensure device makers include adequate security in their products, experts say. They charge that part of the problem is that the agency lacks the funds and the trained personnel to evaluate the cyber risk the devices carry and enforce the rules it does have on the books for approving devices. “I’ve spoken to device manufacturers, specifically product security people at device manufacturers, saying that they’ve been telling their organizations for the last year or two that they need to include cybersecurity as part of their submissions or else they’re going to get rejected,” said Mike Kijewski, CEO of medical device cybersecurity firm MedCrypt. “Yet for some of their recent submissions, they didn’t have a lot of cybersecurity documentation and they still got accepted by the FDA.” Cyberattacks remain a significant risk for healthcare companies. US patient safety group ECRI reported 173 medical device cybersecurity alerts in the past five years. The organisation warned that cybersecurity incidents don’t just disrupt business operations, but can “pose a real threat of physical harm.” For instance, ransomware attacks on hospitals can cause device outages that disrupt patient care, and at worst, put lives at risk. Read full story Source: MedTech Dive, 11 August 2022
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