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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Gallery Image
    Storage and labelling
    Similar looking boxes, but different drugs, stored together on the shelf. Easy to pick the wrong one up.
  2. Event
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    150 high-level participants spanning across G20+ countries will discuss with G20 policymakers and politicians, government ministers, multilateral organisations, the global health community, the private sector, economists, civil society, and academia how to create a new age of partnerships and positive sustainable interdependencies of the many global and national COVID-19 learning initiatives. Participants will discuss and suggest how to advance the nexus of health and socio-economic impact to not only avoid a future pandemic, but transform health systems for good. The H20 Summit will make joint recommendations to the upcoming G20 Health Ministers and Leaders Meeting in October and November 2022. Register
  3. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to the use of a flush fluid and blood sampling from an arterial line in people who are critically ill in hospital. As its ‘reference case’, the investigation uses the experience of Keith, a 66 year old man who during a stay in a clinical care unit had blood samples taken from an arterial line which were contaminated with the flush fluid containing glucose. As a result he received incorrect treatment which led to his blood glucose levels being reduced to below the recommended limit.
  4. News Article
    Major reforms have been set out on how NHS organisations should respond to patient safety incidents, which are aimed at ensuring better engagement with patients and families. The Patient Safety Incident Response Framework (PSIRF), published today, replaces the serious incident framework and provides guidance to trusts on how and when they should conduct investigations. According to NHSE, a key aim is to allow trusts to focus resources on where investigations will have the greatest impact, rather than investigating all incidents as they did under the old framework. NHSE said the more flexible approach should make it easier to address concerns specific to health inequalities, as incidents can be learnt from that would not have met the serious incident definition. However, it does not affect the need for a patient safety incident investigation following a never event’ or maternity incident; this is still required. Helen Hughes, chief executive of charity Patient Safety Learning, said the new framework “places an emphasis on individual organisations assessing their patient safety risks”, and provided a “welcome acknowledgement of the importance of engaging patients and families as part of the investigation process”. However, she said there would need to be a “significant training programme for staff in a range of human factors informed approaches”, to ensure reviews lead to safety improvements. She added: “What is being proposed is a complex innovation in the NHS’s approach to incident investigation. Its success to a large part will depend on having the right organisational leadership and resources to support this transition. [NHSE has] now provided a set of tools and a timetable for this. However, ultimately this initiative should be judged on its implementation and effectiveness in reducing avoidable harm.” Read full story (paywalled) Source: HSJ, 16 August 202
  5. News Article
    NHS England has said integrated care systems (ICSs) will be responsible for ‘initial problem solving and intervention’ if trusts fail to deliver against key targets to prepare for winter. NHSE’s letter on winter planning and response, published on Friday, said system working “means a new approach to accountability” and that ICBs – the NHS executive of ICSs – would be accountable for ensuring that providers and others “deliver their agreed role in their local plans and work together effectively”. The document, signed by NHSE’s leadership, says: “ICBs are responsible for initial problem solving and intervention should providers fail, or be unable, to deliver their agreed role. “Intervention support can be provided from NHS England regional teams as required, drawing on the expertise of our national level urgent and emergency care team as needed.” Read full story (paywalled) Source: HSJ, 15 August 2022
  6. News Article
    The UK has become the first country to approve a dual vaccine which tackles both the original Covid virus and the newer Omicron variant. Ministers say the vaccine will now form part of the autumn booster campaign. Moderna thinks 13 million doses of its new vaccine will be available this year, but 26 million people are eligible for some form of booster. Health officials say people should take whichever booster they are offered as all jabs provide protection. Moderna's latest vaccine - called Spikevax - targets both the original strain and the first Omicron variant (BA.1), which emerged last winter. It is known as a bivalent vaccine as it takes aim at two forms of Covid. The UK's Medicines and Healthcare Products Regulatory Agency has considered the evidence and given the vaccine approval for use in adults. Dr June Raine, the regulator's chief executive, said: "What this bivalent vaccine gives us is a sharpened tool in our armoury to help protect us against this disease as the virus continues to evolve." Read full story Source: BBC News, 16 August 2022
  7. News Article
    A care home nurse has been struck off after he gave a brain tumour patient sugar and water instead of pain relief. Vijayan Rajoo said he felt the patient was "just being lazy" and did not need pain relief. Rajoo, 64, also failed to check supplies in the controlled drug cupboards at the start and end of his shifts, according to a misconduct panel. He was struck off for 18 months after a deputy manager at the home, St Fillans in Colchester, Essex, discovered 20ml of liquid morphine Oramorph was unaccounted for in June 2019. Rajoo later confessed to not giving the brain tumour patient a dose of Oramorph as a form of pain relief as he felt the patient "did not need it". It was reported the patient could immediately tell the sugar and water mix "didn't taste right". The misconduct panel found all charges against Rajoo proven. In their conclusions, the panel said Rajoo showed a "serious lack of compassion". Read full story Source: ITV News, 13 August 2022
  8. News Article
    Almost 200 maternity units in England will be inspected by the Care Quality Commission amid fears for mothers and babies’ safety and concerns that improvements are not happening fast enough. The commission is taking the unusual step as NHS England faces accusations of pressuring hospitals to reorganise the way midwives work when they lack the staff to do it safely. The new model of care, which is designed to provide mothers with a dedicated midwife throughout pregnancy, has been introduced only partially across the NHS, leading to a two-tier service in which hospital wards are left short of staff and women face potentially dangerous delays. Under “continuity of carer”, midwives work in teams and are on call for specific mothers when they go into labour. But this can leave hospital wards understaffed and women not included in the programme waiting for a midwife. NHS England is pushing hospitals to make this the default model of care by March 2024 despite a warning by Donna Ockenden, who led the inquiry into baby deaths at the Shrewsbury and Telford Hospital Trust, and who said in her final report that introduction of the new model should be suspended if services lack enough staff. Read full story Source: The Times, 14 August 2022 Further reading - Midwifery continuity of carer resources on the hub.
  9. Content Article
    The Centre for Sustainable Healthcare hosts and supports a number of networks to enable communities of like-minded people to collaborate internationally on sustainability in their clinical specialty or area of interest. Whether you are a patient, health professional, commissioner, educator or other, you can sign up or log in to join in discussion, find out about events and resources, ask questions and share ideas for sustainable healthcare in your field.
  10. Content Article
    Patients and providers often don't recognise skin cancer on darker skin. Medical school faculty and students are trying to change that.
  11. News Article
    The GMC has responded to senior medical leaders’ frustration at news that the Government is again delaying long-promised plans for its reform which would ease the strain felt by doctors. Its chief executive said its Council shared widespread disappointment at the hold-up in changing the legislation – which was expected this year, but will not now happen until 2024-25. Charlie Massey told Independent Practitioner Today: "Physician associates and anaesthesia associates are an important part of the health workforce and we welcome progress to bring them into regulation, which we will do within 12 months of legislation being laid by Government. "But we are disappointed that the outdated legislation for doctors will not be replaced at the same time. "The current framework stops us from being responsive and flexible in how we address patient safety concerns and register doctors to join the UK workforce. That isn’t good for patients and puts unnecessary strain on doctors. "The Government has said that it expects to deliver reforms for doctors as a priority following its work on physician associates and anaesthesia associates." Mr Massey called for a clearer commitment on the specific timing of that work, adding that the GMC wanted to progress better regulation for both doctors and medical associate professionals (MAPs) as soon as the Department of Health and Social Care laid the necessary legislation. "It is now the department’s decision when and how to implement these changes. When the department does implement these changes, we will be ready to start the process to put the reform changes into practice," he said. Read full story Source: Independent Practitioner Today, 9 August 2022
  12. Content Article
    RAND Corporation and MedStar researchers examined the intersection of patient safety and racism, focusing on patient safety and health equity from clinician leaders' perspectives. An overarching emphasis of the work concerned the impact of racism and other related factors (i.e., bias) on patient safety events and potential interventions or changes (such as creating a culture of speaking up about racism in care) that can help prevent such events.
  13. Content Article
    Adverse incident research within residential aged care facilities (RACFs) is increasing and there is growing awareness of safety and quality issues. However, large-scale evidence identifying specific areas of need and at-risk residents is lacking. This study from St Clair et al. used routinely collected incident management system data to quantify the types and rates of adverse incidents experienced by residents of RACFs.
  14. News Article
    Legal costs in some lower-value medical negligence claims can be double or even triple the amount of compensation paid to patients. Figures in the Medical Defence Union’s (MDU’s) annual report for 2021 reveal the average sum paid in claimants’ legal costs on medical claims settled for up to £10,000 was in excess of £18,500. For claims settled between £10,000 and £25,000, the average was nearly £35,000. The not-for-profit indemnifier called on the Government to proceed quickly with the reforms needed to the clinical negligence system to make disproportionate legal costs a thing of the past. Its chief executive Dr Matthew Lee said: "Disproportionate legal costs are one of several defects in the current litigation system and particularly affect lower value claims. "It cannot be right for legal costs paid to claimants’ lawyers to regularly exceed the damages paid to claimants by double or triple the amount." Read full story Source: Independent Practitioner Today, 9 August 2022
  15. Content Article
    As dentists hand back their NHS contracts in record numbers, GPs are seeing the impact on their workload and patients’ health, especially in “dental deserts,” reports Sally Howard in this BMJ article. Over one week this spring, 20 patients presented at GP Abbie Brooks’ York surgery with abscesses, dental pain, and broken teeth—demanding antibiotics and painkillers. Brooks could not prescribe because she was not indemnified to perform dental work. Many of these patients, Brooks says, were not registered with a dentist or able to find an NHS dentist, and had already been told to call 111. The NHS medical helpline had advised patients to visit emergency NHS dentists 50 miles away from Brooks’ surgery. “Vulnerable patients often can’t get to emergency dentist appointments in Bradford or Leeds for logistical or financial reasons,” she says, adding that a small proportion of patients became difficult when Brooks was unable to help. “One woman was really quite angry that I wouldn’t incise and drain her abscess,” she says. “It’s not acceptable for GPs to have to deal with this crisis not of our doing.”
  16. Content Article
    This download is the first of three chapters of a book which complements the Chartered Institute of Ergonomics and Human Factors' Healthcare Learning Pathway and is intended as a practical resource for students
  17. News Article
    A woman with fast-growing stage-four breast cancer says the NHS has let her down, with delays at every stage of her treatment. Caroline Boulton, 56, had several appointments for a mammogram, which checks for early signs of cancer, cancelled because of Covid, in March and November 2020. In late 2021, she found a small lump, went to her GP and was referred urgently to a specialist - but then the delays began. "They haven't moved quickly enough," Ms Boulton says, who lives in Greater Manchester. "It's been really, really slow." "Between each appointment, each scan, there's been four-, five-, six-, seven-, eight-week waiting times and delays every time." The referral letter came through "very quickly" but then she waited three weeks, instead of the recommended two, to see a consultant. "When I first found the lump, it was only pea-sized," Ms Boulton says. "By the time I got to see the consultant, it was the size of a tangerine." Her cancer was growing quickly, she was told, but it would be eight weeks before a mastectomy could be scheduled to remove her breast. "Considering it was fast-growing, that's a huge concern - you're living with that, waiting, knowing it's growing," Ms Boulton says. When she finally saw an oncologist seven months after finding the lump, had another scan and received the results, the cancer had spread to her liver - and there was no longer any treatment they could offer. "I've now got stage-four cancer that I shouldn't have - and two years to live." Read full story Source: BBC News, 10 August 2022
  18. News Article
    A cyber attack that has caused a major outage of NHS IT systems is expected to last for more than three weeks, leaving doctors unable to see patients’ notes, The Independent has learned. Mental health trusts across the country will be left unable to access patient notes for weeks, and possibly months. Oxford Health Foundation Trust has declared a critical incident over the outage, which is believed to affect dozens of trusts, and has told staff it is putting emergency plans in place. One NHS trust chief said the situation could possibly last for “months” with several mental health trusts, and there was concern among leaders that the problem is not being prioritised. In an email to staff, Oxford Health Foundation Trust chief executive Nick Broughton, said: “The cyber attack targeted systems used to refer patients for care, including ambulances being dispatched, out-of-hours appointment bookings, triage, out-of-hours care, emergency prescriptions and safety alerts. It also targeted the finance system used by the Trust." The NHS director said: “The whole thing is down. It’s really alarming…we’re carrying a lot of risk as a result of it because you can’t get records and details of assessments, prescribing, key observations, medical mental health act observations. You can’t see any of it…Staff are going to have to write everything down and input it later.” They added: “There is increased risk to patients. We’re finding hard to discharge people, for example to housing providers, because we can’t access records.” Read full story Source: The Independent, 11 August 2022
  19. News Article
    England’s mental health inpatient system is “running very hot” and operating well above recommended occupancy levels, HSJ has been told, as new funding to address the problem is revealed. The move was announced by NHS England mental health director Claire Murdoch in an exclusive interview with HSJ. It comes amid a steep rise in mental health patients waiting more than 12 hours in accident and emergency. Last month, an HSJ investigation revealed 12-hour waits for people in crisis had ballooned by 150% in 2022 compared to pre-pandemic levels. Problems finding specialist beds have been cited by experts as one of the root causes of A&E breaches. Ms Murdoch told HSJ the funds would not come from ”within the mental health service budget” and that they would be used to “help address any pressures where we think the answer is more of either beds or other urgent and emergency care which has a capital need.” NHSE is now working with the 42 integrated care systems to determine where the money can best be used. Ms Murdoch said the money would be spent ”where there is a particular need” and that there was “no blanket approach” to its allocation. Read full story (paywalled) Source: HSJ, 10 August 2022
  20. Content Article
    15 seconds 30 minutes (or 15s30m for short) aims to help anyone identify how they could spend a few extra seconds on a task now which will save someone else 30 minutes or more later on. In doing so you will reduce frustration and increase joy. Joy in work has been proven to help staff to do their best and deliver safe and effective patient care. Improving joy is the key to retaining the workforce and reducing staff sickness. And who doesn’t want to enjoy coming to work every day! 15s30m is a change platform which individual staff or patients or whole organsiations can use to release the value in every idea. To get started you don’t need a charter or formal plan or programme initiation document: its just individuals being empowered to do what they know is right for staff and patients.
  21. News Article
    All children aged one to nine and living in Greater London will be offered a polio vaccine after the virus was detected in sewage. The virus, which can cause paralysis, has been found 116 times in London's wastewater since February. The urgent immunisation campaign will see nearly a million children offered the vaccine - including those already up to date with their jabs. Parents and carers will be contacted by their GP within the next month. Polio is seen as a disease of the past in the UK after the whole of Europe was declared polio-free in 2003. Dr Vanessa Saliba, a consultant epidemiologist at UKHSA, said: "All children aged one to nine years in London need to have a dose of polio vaccine now - whether it's an extra booster dose or just to catch up with their routine vaccinations." She said the risk for the majority of the population who are vaccinated remains "low" but said it was "vital" parents ensure their children are fully vaccinated. Read full story Source: BBC News, 10 August 2022
  22. News Article
    A 35-year-old mum says she's been left crippled by surgical mesh implanted into her body allegedly without her informed consent. Listen to her story here or click on the video below. Source: New Zealand Herald, 9 August 2022
  23. Event
    This Westminster Health Forum policy conference will examine the key priorities for the future of cancer prevention, diagnosis, care and treatment as the Government develops a 10-year Cancer Plan for England. Delegates will discuss priorities for the next stage of the elective care backlog delivery plan, including meeting demand as waiting times for new referrals increase, and what can be learned from success in clearing the longest waiting times for patients. With questions about the future of the National Insurance increase and social care funding, it will be an opportunity to discuss priorities for the Government under a new prime minister. Overall, areas for discussion include: the pandemic - assessing its impact on cancer services and patient care - the future for personalised care in England reducing cancer waiting times - options for increasing capacity - priorities for diagnostics, infrastructure and the use of digital technology - building workforce resilience and retention the 10-year Cancer Plan for England - stakeholder perspectives on next steps in its development screening programmes - progress in recovering services and options for future delivery - developing public awareness health outcomes - improving early diagnosis and access to innovation - use of data and developing prevention programmes to meet local need - addressing accessibility and health inequalities personalised care - the future for patient engagement and involvement in their own care plans - how this should look within cancer care in England. Agenda Register
  24. Event
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    In the face of new challenges, developing requirements, and restructuring of local systems within the NHS it’s vital to bring together the Digital Health community again. HETT 2022 will explore the systems and infrastructure that underpin and enable a data-driven NHS, supporting the ecosystem to deliver patient outcomes through the meaningful implementation of technology. Two days of free CPD accredited educational sessions, interactive activities, and networking opportunities with 150+ innovative suppliers and 200+ expert speakers. Further information and registration
  25. News Article
    The Senate passed a sweeping budget package Sunday intended to bring financial relief to Americans, but not before Republican senators voted to strip a proposal that would have capped the price of insulin at $35 per month for many patients. A proposal that limits the monthly cost of insulin to $35 for Medicare patients was left untouched. But using a parliamentary rule, GOP lawmakers were able to jettison the part of the proposal that would apply to privately insured patients. Lowering the price of drugs such as insulin, which is used by diabetics to manage their blood sugar levels, is broadly popular with voters, polling shows. Senate Democrats denounced Republicans for voting against relief for Americans struggling to pay for the lifesaving drug. More than 30 million Americans have diabetes, and about 7 million require insulin daily to manage their blood sugar levels. The insulin price cap, part of a larger package of proposals to cut prescription drug and other health-care costs, was intended to limit out-of-pocket monthly insulin costs to $35 for most Americans who use insulin. More than 1 in 5 insulin users on private medical insurance pay more than $35 per month for the medicine, according to a recent analysis from the Kaiser Family Foundation. The same analysis found that the median monthly savings for those people would range from $19 to $27, depending on their type of insurance market. A Yale University study found insulin is an “extreme financial burden” for more than 14% of Americans who use it. These people are spending more than 40% of their income after food and housing costs on the medicine. Read full story (paywalled) Source: The Washington Post, 8 August 2022
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