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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
    This one day masterclass will focus on how an organisation can increase staff engagement and with it improve patient experience. This masterclass focuses on staff experience and improving engagement which is particularly important when staff are under pressure during Covid-19. It looks at how to improve engagement through a healthy, compassionate and inclusive culture. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/outstanding-staff-engagement or email aman@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code.
  2. Event
    This national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the new Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) a version of which has now been published and which is being tested in early adopter sites. NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version with the revised framework due in Summer 2022. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email kate@hc-uk.org.uk hub members receive 20% discount. Email info@pslhub.org for discount code Follow on Twitter @HCUK_Clare #NHSSeriousIncidents
  3. Event
    This masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key learning objectives: Understanding the role of the Senior Information Risk Owner. Identifying information risks across the organisation. Working with others to mitigate the risk to patients, staff and organisation. Confidence that all reasonable technical and organisation measure are in place. Giving assurance to the Board that risks have been considered, mitigated or owned. Understand the requirements of external confidence that policies, procedures are in place to deal with Data Breaches. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/masterclass-developing-your-role-as-a-senior-information-risk-owner-siro or email kate@hc-uk.org.uk hub members receive 20% discount. Email info@pslhub.org for discount code.
  4. Event
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    This intensive two-day masterclass will provide Root Cause Analysis training in line with the 2019 Patient Safety Strategy and subsequent guidance. The course will offer a practical guide to conducting RCA with a focus on systems-based patient safety investigation as proposed within the latest guidance released by NHS England and NHS Improvement. The course provides insights into how RCA is evolving and gives detailed information on what standards RCA investigations are expected to reach following the detailed recent reviews of patient safety work across the NHS and healthcare. To register go to https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-2-day-masterclass or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for a discount code.
  5. Event
    This one day masterclass will focus on improving Patient Safety through enhancing psychological safety and safety culture. It looks at effective ways to encourage health professionals to routinely embed high-quality clinical evidence into their everyday work. It explores the characteristics of relatively successful behaviour change interventions. All Clinical Staff and Team Leads should attend. For further information and to book your place visit www.healthcareconferencesuk.co.uk/conferences-masterclasses/improving-psychological-safety-patient-safety or email kerry@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code.
  6. Event
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    This year's Institute for Healthcare Improvement will take place in person on December 4–7 in Orlando, Florida, and online 13–15 December.
  7. News Article
    A trust which is struggling with a new electronic patient record (EPR) is likely to see cancer performance affected for at least the rest of this year, it has said. Ashford and St Peter’s Hospitals Foundation Trust has set up eight workstreams to ensure its EPR – supplied by Oracle Cerner – is “functioning safely, efficiently and as effectively as possible” after a host of problems since it went live in May. Cancer areas affected include breast, breast symptomatic two week waits, and dermatology. “It is expected that the impact of the introduction of SSC [Surrey Safe Care, the name of the project] will be felt in aspects of our cancer performance until at least December 2022,” July’s board meeting was told. The performance report warned the risk of delays causing harm to cancer patients – currently rated at 12 on the risk register – was being reviewed as a result of the introduction of SSC and was expected to rise. Read full story (paywalled) Source: HSJ, 8 August 2022
  8. News Article
    Armed police are being sent to save the lives of people in cardiac arrest because ambulances “can’t cope” with demand, The Independent has revealed. Officers are spending up to a third of their time on non-policing matters, a watchdog has warned, including responding to mental health crises and transporting patients to A&E as ambulance services face a “chronic crisis situation”. Andy Cooke, HM chief inspector of constabulary, said that firearms officers have been responding to pleas from struggling NHS colleagues to respond to cardiac arrests. He told The Independent that police are becoming the “first, last and only resort” as NHS services buckle under strain, taking them away from tackling crime at a time when recorded offences are at a record high in England and Wales. Mr Cooke, the former chief constable of Merseyside Police, added: “Recently, officers in armed response vehicles (ARVs) were being sent to reports of people who were having cardiac arrests because the ambulance service couldn’t cope with the demand, because they’re trained in first aid and to use defibrillators." “The ambulance service contacted the police to say ‘we’ve got this heart patient and we haven’t got anyone to send’." “Being first, last and only resort, the police will go. It’s right that they did go but that hides the problems we’ve got in the rest of the system.” Read full story Source: The Independent, 8 August 2022
  9. Content Article
    Alcoholism, more professionally termed alcohol use disorder (AUD), is a widespread and costly behavioural health condition. The aims of this paper from Zipperer et al. are draw attention to systemic gaps in care for patients with AUD and advocate for patient safety leaders to partner with both the mainstream medical and substance abuse treatment communities to reduce harm in this patient population.
  10. Content Article
    The US's response to monkeypox fails to put patients and their care at its centre, writes Eric Kutscher in the BMJ opinion article. As a primary care and addiction medicine physician, Kutscher has been dismayed by the number of patients he has treated over the past few weeks who’ve been infected with the vaccine-preventable monkeypox virus. Most have been in considerable pain and required strong analgesics, with some unable to even sit because of their skin lesions. Yet for many, the most agonising and scarring aspect of their infection is not their physical symptoms, but the complete removal of their humanity by the medical response to monkeypox. As a medical and public health community, we are exhausted after Covid-19, and our compassion fatigue is showing in our policies and procedures for monkeypox. The spread of the virus to previously non-endemic countries was only recently declared a public health emergency of international concern by the World Health Organization. Unlike with Covid-19, this is not a novel virus—we have the appropriate diagnostic testing, treatment, and even vaccines that we need. Yet, just as we have failed to deploy these tools to assist in outbreaks in African nations, we are now also failing our patients from a sexual minority—patients who are already underserved and justifiably mistrusting of a medical system.
  11. Community Post
    Extremely painful hysteroscopy | Care Opinion
  12. News Article
    A single system to report patient safety concerns would “keep people safer”, a newly appointed NHS watchdog has told HSJ. Henrietta Hughes – who will take up the post of patient safety commissioner in September – said both clinicians and patients faced a bewildering choice when looking to raise a safety concern, and that there was a need for a “report once” system. She said that when ”exhausted” clinicians “come to the end of a 12-hour shift, they don’t want to have to do a Datix report and a yellow card report, and if they’ve got a safeguarding concern or a concern about an individual condition, [to have to] send that somewhere else”. Dr Hughes added: ”Wouldn’t it be better if we had one report that you do, and all the information that comes from that report just gets sent to the appropriate authority? That’s the type of change that I think we’d like to see. I know, as a GP myself, that’s what I would rather do as a professional. But also, I think, for all the organisations, we could get so much more richness of information, we would get more reporting, and we’d keep people safer as a result of it.” She added that if a patient “wanted to report an individual clinician” they often ended getting bounced around the system, like a pinball. They get sent from pillar to post.” Read full story (paywalled) Source: HSJ, 8 August 2022
  13. Content Article
    Are you currently working on an inpatient mental health ward in the UK? NHS Oxford University Hospitals would like to learn about how you feel towards restrictive practices on mental health wards. Follow the link below to take part.
  14. News Article
    The number of patients unable to get a hospital appointment after being referred by their GP is up more than 50% in two years amid the record NHS backlog, official data show. NHS Digital figures show no appointments were immediately available for 2.3 million referrals made in the first six months of this year – up 51% on the same period in 2020. Appointment slot issues occur when a patient is referred by their GP through the NHS e-Referral Service but no appointment is available to book. The referral is then forwarded or deferred to a patient’s chosen provider, but if an appointment is not made within 180 days it will automatically be removed from the system, according to NHS Digital. Patient safety campaigners have said the scale of the problem must be “urgently investigated” by NHS England to ensure the safety of patients is not being compromised while they wait for appointments. Helen Hughes, the chief executive of the Patient Safety Learning charity, said: “We have significant concerns about the safety of patients who are facing increasingly long waits for treatment, particularly those on high priority cancer pathways and urgent referrals.” She said patients needed to be assured that they will “not be lost in a failing, complex system”, adding: “We believe that NHS England needs to urgently investigate, quantify the scale of the problem and take action if we are to prevent these capacity and system issues resulting in avoidable harm for patients.” Some GPs told Patient Safety Learning they had experienced difficulties getting referrals accepted. One GP, based in the North East, said: “There is an ever-creeping transfer of management of complex conditions from secondary to primary care, without adequate training or resources to manage this safely.” Read full story (paywalled) Source: The Telegraph, 7 August 2022 You may also be interested in Patient Safety Learning's blog: Rejected outpatient referrals are putting patients at risk and increasing workload pressure on GPs
  15. News Article
    Many NHS 111 services are without a crucial IT system for several days, after a cyber attack on a software supplier. Providers had to move to pen-and-paper yesterday, and have been unable to access patient records. Adastra – which is used by 85% of NHS 111 providers – went offline at 7am on Thursday. It was still affected as of Sunday, and staff were told it may not be online for several days. Advanced, which supplies Adastra, confirmed on Friday evening the incident was caused by a cyberattck, but says it managed to limit the damage to a small number of its servers. It was reported on Saturday that the attack is thought to have been by a criminal group trying to extort money — so-called ransomware — rather than an attack by a group linked to a state/government. As well as NHS 111, the system is used by some GP out-of-hours services and has also been marketed to urgent care providers. NHS 111 services have had to use lists of protocols when answering calls and write details down, rather than the software automatically implementing the protocols. One briefing note from commissioners in London, seen by HSJ, described the issue as a “total system outage” for NHS 111, and said “likely delays for patients… will continue throughout the weekend and potentially over next week”. Read full story (paywalled) Source: HSJ, 8 August 2022
  16. News Article
    The NHS has been hit by a shortage of epidural kits to give mothers-to-be, a key form of pain relief during childbirth, as well as the drug that women are offered as an alternative. Supplies of epidural kits and the painkiller Remifentanil are now under such pressure that some hospitals cannot offer pregnant women their usual right to choose which one they want to reduce labour pains. Anaesthetists have told the Guardian that the simultaneous shortage of both forms of pain management has led to “difficult discussions” with women who had been told during their antenatal care that they would have that choice but were upset to learn that it was not available. The disruption to supplies of epidural kits is so acute that NHS Supply Chain (NHSSC), the health service body that ensures hospitals in England and Wales receive regular supplies of drugs and equipment, to ration deliveries to just one week’s worth of stock. Childbirth organisations voiced their concern and warned that the disruption to supplies meant some women in labour were already facing long delays before they received pain relief. “Offering a choice of options during birth is an integral element of good maternity care, and this includes pain relief. It is concerning that the shortage of epidural kits and Remifentanil could be denying many that right”, said Jo Corfield, the NCT’s head of communications and campaigns. “We don’t yet fully understand the impact this shortage is having but we have heard of long waiting times to receive pain relief and epidurals.” Read full story Source: The Guardian, 7 August 2022
  17. News Article
    A scheme handing payments to those affected by the contaminated blood scandal will be announced this week, as ministers scramble to help those harmed by the “historic wrong”. Whitehall sources confirmed that a programme handing interim payments will be confirmed in the coming days, once officials have ironed out issues to ensure that victims are not taxed on the payments or have their benefits affected by them. It is thought that ministers accept recent recommendations that infected people and bereaved partners should get “payments of no less than £100,000”. More than 4,000 people are in line for the payment. Kit Malthouse, the cabinet office minister, has been prioritising the scheme in the last week to ensure payments are made as soon as possible. “The infected blood scandal was a tragedy for everyone involved, and the prime minister strongly believes that all those who suffered so terribly as a result of this injustice should receive compensation as quickly as possible,” said a No 10 source. “He has tasked ministers with resolving this issue so that interim payments can be made to all those infected as soon as possible, and we will set out the full details later this week.” Read full story Source: The Guardian, 6 August 2022
  18. News Article
    Nine in 10 NHS dental practices across the UK are not accepting new adult patients for treatment under the health service, a BBC investigation has found. BBC's research shows no dentists taking on adult NHS patients could be found in a third of the UK's top-tier councils. And eight in 10 NHS practices are not taking on children. The Department of Health said it had made an extra £50m available "to help bust the Covid backlogs" and that improving NHS access was a priority. BBC News contacted nearly 7,000 NHS practices - believed to be almost all those offering general treatment to the public. The British Dental Association (BDA) called it "the most comprehensive and granular assessment of patient access in the history of the service". While NHS dental treatment is not free for most adults, it is subsidised. The BBC heard from people across the UK who could not afford private fees and said the subsidised rates were crucial to getting care. The lack of NHS appointments has led people to drive hundreds of miles in search of treatment, pull out their own teeth without anaesthesia, resort to making their own improvised dentures and restrict their long-term diets to little more than soup. Read full story Source: BBC News, 8 August 2022
  19. News Article
    Pelvic mesh campaigner Kath Sansom has met with the health secretary Steve Barclay to discuss financial redress for those suffering complications from the procedure. The UK government decided last year not to provide compensation to women whose lives had been affected by vaginal mesh implants. But Kath Sansom, a Cambridgeshire mum and former journalist for this news outlet, has continued campaigning and says she will put pressure on the health secretary to revisit the issue. It also comes as the government revealed victims of the 1970s and 1980s blood scandal will receive compensation for the impact it has had on their lives. Ahead of her meeting with the Secretary of State for Health, she said: “We [mesh injured] deserve to be compensated based on the fact we are suffering lifelong damage from a health treatment that caused avoidable harm. “It is not our fault this happened to us and the State should take responsibility.” Former Health Secretary Matt Hancock issued a public apology when a public inquiry in 2020 revealed a shocking extent of patient failings and lack of regulation for mesh victims. “The State has apologised for the suffering of the mesh community, which is an acknowledgement of responsibility,” Kath added. Read full story Source: Cambs Times, 5 August 2022
  20. Content Article
    Climate change poses a major threat to our health. Tackling climate change through reducing harmful carbon emissions will improve health and save lives. Here in the UK, air pollution is the single greatest environmental threat to human health, accounting for 1 in 20 deaths. Reducing emissions will mean fewer cases of asthma, cancer and heart disease. In response to the health threat posed by climate change, the NHS became the world’s first health service to commit to a target of reaching net-zero carbon emissions by 2040.
  21. Content Article
    The UK has fewer hospital beds than almost any other European comparator and we can ill afford any loss of hospital capacity. While Covid has undoubtedly worsened performance, crowding in emergency departments was a problem before the pandemic. There are frantic attempts to shore up battered and fragile rotas and rota coordinators are scratching their heads. Meanwhile there has been a steady increase in the number of staff off work with Long Covid. While many have been flexible and accommodating to try to maintain their services, there is increasing burnout and uncertainty as to when all this will end. The workforce needs to feel valued and supported, writes Adrian Boyle, a consultant in emergency medicine. There needs to be an acknowledgment that the system is broken.
  22. Content Article
    It is 20 years since researchers discovered that patients admitted to hospitals on Saturdays or Sundays are more likely to die than those admitted Monday to Friday. The ‘weekend effect’ was assumed to be because fewer hospital specialists work at weekends, meaning care was less good. However, there was no evidence to support this assumption. This NIHR Alert is based on: This NIHR Alert is based on: Bion J, and others. Increasing specialist intensity at weekends to improve outcomes for patients undergoing emergency hospital admission: the HiSLAC two-phase mixed-methods study. Health Services and Delivery Research 2021;9:13.
  23. Content Article
    Foreign body ingestions are common events among paediatric patients. Button battery ingestions are particularly dangerous. Although the incidence of button battery ingestions has not changed over the last 30 years, the rates of emergency department visits, major morbidity, and mortality have risen dramatically since the introduction of the 3-volt–20 mm lithium batteries in 2006. These batteries are larger and more powerful than their predecessors, which has increased the incidence of esophageal impaction and significant tissue injury.  The overall incidence of major morbidity or mortality after button battery ingestion is 0.42%. However, in children under six years old who ingest batteries >20 mm, the rates of major complications are as high as 12.6%. All reported fatalities have occurred in children under five years old. This article in the Anesthesia Patient Safety Foundation newsletter looks at the perioperative management of children who have ingested a button battery.
  24. Content Article
    The importance of nurse staffing to the delivery of high-quality patient care was a principal finding in the landmark report of the Institute of Medicine’s (IOM) Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes: “Nursing is a critical factor in determining the quality of care in hospitals and the nature of patient outcomes”. Nurse staffing is a crucial health policy issue on which there is a great deal of consensus on an abstract level (that nurses are an important component of the health care delivery system and that nurse staffing has impacts on safety), much less agreement on exactly what research data have and have not established, and active disagreement about the appropriate policy directions to protect public safety. Researchers have generally found that lower staffing levels are associated with heightened risks of poor patient outcomes. Staffing levels, particularly those related to nurse workload, also appear related to occupational health issues (like back injuries and needlestick injuries) and psychological states and experiences (like burnout) that may represent precursors for nurse turnover from specific jobs as well as the profession. This chapter from the Patient Safety and Quality: An Evidence-based Handbook for Nurses summarises and discusses the state of the science examining the impact of nurse staffing in hospitals and other health care organisations on patient care quality, as well as safety-focused outcomes. To address some of the inconsistencies and limitations in existing studies, design issues and limitations of current methods and measures will be presented. The chapter concludes with a discussion of implications for future research, the management of patient care and public policy.
  25. Content Article
    Decisions formed from a diversity of opinions usually lead to better long-term outcomes. So, when you believe that your team or organisation is missing something important, moving in the wrong direction, or taking too much risk, you need to speak up. Done effectively, dissent challenges groupthink, reminds those in the majority that there are alternatives paths, and prompts everyone to get creative about solutions. Six decades of scientific research point to strategies those without formal power can use to make sure their dissenting ideas are heard. First, pass the in-group test by showing how you fit in. Then pass the group threat test by showing how you have your team’s best interest at heart. Make sure your message is consistent but creative tailored for different people, lean on objective information, address obstacles and risks, and encourage collaboration. Finally, make sure to get support. Dissent isn’t easy but it can be extremely worthwhile.
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