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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Tommy Greene and David Hencke report on a number of worrying NHS dismissal cases in this Byline Times article.
  2. Content Article
    As organisations continue to adapt to a faster pace of change and seek to achieve their organisational purpose, it’s essential that the resources and time needed to change are minimised. Improving performance by learning effectively from mistakes is a vital part of the change process but the method of learning employed is critical. In this LinkedIn post, Judy Walker discusses the application of After Action Reviews (AARs).
  3. Content Article
    Professor Peter Brennan is a NHS Consultant Surgeon in Portsmouth, specialising in head and neck cancer. In this episode of the Human Factor Podcast, Peter discusses how he is driving Human Factors approaches from his perspective. To date, Peter has published over 700 publications including more than 80 on Human Factors and patient safety. His HF work has changed the delivery of postgraduate surgery exam delivery in the UK and abroad. Watch all the Human Factors Podcast episodes here.
  4. Content Article
    Professor Ron McLeod's presentation on the Chartered Institute of Ergonomics & Human Factors (CIEHF) White Paper on Human Factors in highly automated systems.
  5. News Article
    On 24 June the US Supreme Court overturned Roe v Wade, the 1973 decision that legalised abortion and left the regulation of abortion to the states.4 At present, about half of the 50 states ban or severely limit abortions, but the picture is changing daily as century old bans go into place in some states, bans are challenged in courts, and state legislatures debate changes to their laws. The American College of Obstetricians and Gynecologists (ACOG) said, “Each piece of legislation is different, using different language and rationales. State legislators are taking it upon themselves to define complex medical concepts without reference to medical evidence. Some of the penalties for violating these vague, unscientific laws include criminal sentences.” Doctors report being confused and fearful about how they can continue to practise in states where abortion laws are changing day by day and sometimes hour by hour. Katie McHugh, an obstetrician and gynaecologist in Indianapolis, where abortion until 20 weeks is legal for the moment, told The BMJ about a patient who arrived from another state (around 200 miles away) with a miscarriage. “A fetal heartbeat could still be detected. The local hospital sent her home and told her to come back if she became very sick.” Instead she travelled two and a half hours by car to McHugh. “I don’t blame the physicians in [the other state]. I don’t know if abortion is legal now a trigger law is in effect. They could face lawsuits. As a physician, it’s unacceptable to have to watch the news to know what’s legal and how to practise,” said McHugh. Read full story Source: BMJ, 1 August 2022
  6. News Article
    A&E waits are now “apocalyptic” and “worse than ever imagined” leaked NHS data shows, and could be driving 1,000 patient deaths a month, The Independent can reveal. Almost 700,000 people have waited more than 12 hours in A&E in the first seven months of 2022, according to leaked NHS data. The “hidden” monthly trolley waits, not published in national data, have more than doubled this year in comparison to 2019. Dr Katherine Henderson, President of the Royal College of Emergency Medicine, warned data shows trolley waits are “worse than ever imagined” and said it is “scandalous” the real figures are not published despite promises. Dr Henderson warned the deterioration in A&E waiting times is the result of “decades of underfunding” and “unheeded warnings” over staffing and social care. In one message to staff in Nottinghamshire, seen by The Independent, hospital leaders said last week patients were waiting more than 40 hours for beds in A&E, while some areas of the hospital were running on a 1:14 staffing ratios and patients were waiting at home with no care. Read full story Source: The Independent, 1 August 2022
  7. News Article
    Hospitals must start using “smart” intravenous (IV) infusion technology to its full potential if they are to prevent dangerous drug errors, University of Manchester researchers have found. ‘Smart pumps’- which automatically calculate the dose and rate of different drugs before they are pumped into a vein - prevent potentially fatal errors by stopping the administration of the wrong rate. But according to the study published in BMJ Open Quality, though the technology probably saved the lives of 110 people in two Trusts over a year, it has largely failed to be adopted by hospitals. Though many IV pumps used in hospitals have a smart capability, most trusts do not utilise the functionality because they are difficult to configure and maintain. Smart pumps are usually configured by a pharmacist and checked by a consultant or senior nurse. Conventional pumps, however, are set by ward staff who calculate and input infusion rates themselves - increasing the risk of drug errors. The risks are illustrated by previous work from the Manchester team, who demonstrated that 1 in 10 IV drug administrations are associated with an error, and up to 1 in 10 of those were associated with harm. Read full story Source: University of Manchester, 1 August 2022
  8. News Article
    A cancer sufferer who says she faced a wait of 31 hours in A&E has compared the emergency department to "a cattle market". Tracy Summerson, who had nausea and a fever, was eventually admitted to Lincoln County Hospital last week. Ms Summerson said there were more than 30 other patients who waited a similar amount of time. The hospital said despite long waits, those who needed immediate care were "able to be seen and looked after". Ms Summerson, from Scopwick near Metheringham, described the scene as "just crammed, you were like cattle in a market". Ms Summerson, who has stage four malignant melanoma, said: "There was people coming with sick bowls being sick next to you. "When you are immune-suppressed you're supposed to go in a side room out of germs way, but they needed all the rooms for consultations." The family of an 83-year-old woman also contacted the BBC to say she waited more than 40 hours in a wheelchair in her nightdress after being taken to the hospital with a suspected brain bleed. The trust added: "We continue to see an increasing demand on our urgent and emergency care services coupled with patients staying much longer in our hospitals than previously experienced." Read full story Source: BBC News, 1 August 2022
  9. News Article
    Staff at a mental health trust, run by Norfolk and Suffolk NHS Foundation Trust, falsified records that they had checked on a vulnerable patient the night he died, an inquest has heard. Eliot Harris was found dead in his room at Northgate Hospital in Great Yarmouth, Norfolk, in April 2020. A police witness statement detailed how CCTV footage contradicted 19 log entries. Mr Harris, 48, was admitted to hospital after the care home where he was a resident requested an urgent mental health assessment, an inquest into his death at Norfolk Coroner's Court heard. He had been diagnosed with paranoid schizophrenia, had a history of epileptic seizures and had not been taking his medication. Mr Harris was deemed to be high risk and was supposed to be on regular checks four times an hour. In a witness statement read out in court, Det Sgt Nick Appleton described how police had cross referenced logs of his observations with CCTV recordings. Det Sgt Appleton listed 19 instances in which the observation record was signed by a staff member that night, indicating Mr Harris had been checked, but was not backed up by the CCTV record. He identified a number of "points of concern" in his evidence in which falsifying logs was "normal" and "standard practice" on wards. Read full story Source: BBC News, 1 August 2022
  10. News Article
    Several trusts have now started reporting thousands of 12-hour waits in their emergency departments, representing a huge difference to the numbers published nationally under a slightly different measure. This year, trusts have started submitting data to NHS England on the number of patients waiting over 12 hours from time of arrival in ED, until discharge, admission or transfer. Many trusts are now reporting these statistics in their public board reports. This is a slightly different measure to the publicly reported “trolley wait” figures, which count waits of over 12 hours from decision to admit until admission. Experts have long argued the trolley wait measure does not capture the true problem of ED overcrowding and delayed care. The new data captures a far higher number of patients and has not been published nationally by NHSE. Read full story (paywalled) Source: HSJ, 2 August 2022
  11. News Article
    People who go to hospital for non-covid treatment are at higher risk of the virus compared with the general public, which is why high levels of hospital-acquired Covid-19 in England are worrying some doctors. They fear that the coronavirus is becoming a potential hazard of a hospital stay for older or vulnerable people, in a similar way to “superbugs” such as methicillin-resistant Staphylococcus aureus (MRSA). People who go to hospital for non-covid-19 treatment are at higher risk from the virus compared with the general public, says Tom Lawton, an intensive care doctor in Bradford, UK. Read full story (paywalled) Source: The New Scientist, 21 July 2022
  12. Content Article
    The establishment of 42 integrated care systems ushers in an unprecedented opportunity to deliver wide ranging improvements in population health and care as well as wider system performance. If that potential is to be realised, digital and analytics will need to play a central role. How can ICS leaders grasp this opportunity?
  13. Content Article
    M R Rajagopal (known to all as Raj) is an internationally renowned Indian anaesthetist and palliative care physician who is one of the founders of a system of palliative care in Kerala that is admired the world over. The Lancet Commission on the Value of Death said that societies everywhere could learn from the Kerala innovation, which is a system led by the community with health professionals as supporters rather than leaders. Raj has now published his readable, insightful—and at times funny—autobiography, Walk with the Weary: Lessons in humanity in healthcare, which is both a severe critique of modern healthcare and a prescription for transformation and highlighted by Richard Smith in this BMJ article.
  14. Content Article
    Our home is a place where we spend so much more time. However, this is one place where there may be fewer safeguards and less protection from the risks of serious injury, especially to young children. Preventable accidental injury remains a leading cause of death and acquired disability for children in the UK. Moreover, it affects deprived children more. Hospital admission rates from unintentional injuries among the under-fives are significantly higher for children from the most deprived areas compared with those from the least deprived. This short article from Ian Evans highlights what healthcare professionals working with children and families need to know about accidents and accident prevention in a higher income setting.
  15. Content Article
    This landmark report from the Leapfrog Group, an independent national healthcare safety watchdog in the US, is the result of an intensive year-long effort bringing together the nation’s leading experts on diagnostic excellence, including physicians, nurses, patients, health plans, and employers. Together, the multi-stakeholder group reviewed the evidence and identified 29 evidence-based actions hospitals can implement now to protect patients from harm or death due to diagnostic errors. Diagnostic errors contribute to 40,000-80,000 deaths a year, with over 250,000 Americans experiencing a diagnostic error in hospitals. This includes delayed, wrong, and missed diagnoses, and those that are not effectively communicated to the patient.
  16. News Article
    A large acute trust is carrying out a major expansion of patient-initiated follow-up (PIFU) appointments, which is said to be “the most ambitious” project of its kind in the NHS. Norfolk and Norwich University Hospitals Foundation Trust has categorised around half of its outpatient follow-up list as “possible or probable opportunities” for patient-initiated pathways. NNUH wants to make PIFU the “default model” for patients who are not on active pathways, and where it is safe to do this. Its project is being closely watched by national leaders and has already drawn praise from NHS England’s director of elective recovery, Rob Stones, during a webinar last month. It is understood to be more ambitious than NHSE’s official PIFU pilot projects. NHSE’s elective chief, Sir Jim Mackey, has said he wants to expand PIFU pathways on an “industrial” scale. Read full story (paywalled) Source: HSJ, 29 July 2022
  17. News Article
    More than a million people – including hundreds of thousands of children – are on an unpublished national waiting list for community health services, according to NHS England documents leaked to HSJ. They reveal that just over 75,000 children are waiting to access community paediatric services, including children needing help with developmental delay, long-term health conditions and additional needs; and there is a backlog of more than 74,300 young people for speech and language therapy. More than 321,000 adults are on the list waiting for musculoskeletal services, mostly physiotherapy such as for back and joint pain; while 120,000 are waiting for podiatry. HSJ understands the lack of national support for long waits for most community and mental health care – in contrast to billions of government funding and a major recovery programme for elective consultant-led treatment – has been raised at a senior level in NHS E in recent weeks. One senior leader told HSJ the discrepancy was “immoral”. Read full story (paywalled) Source: HSJ, 1 August 2022
  18. News Article
    The NHS is to use artificial intelligence to detect, screen and treat people at risk of hepatitis C under plans to eradicate the disease by 2030. Hepatitis C often does not have any noticeable symptoms until the liver has been severely damaged, which means thousands of people are living with the infection – known as the silent killer – without realising it. Left untreated, it can cause life-threatening damage to the liver over years. But with modern treatments now available, it is possible to cure the infection. Now health chiefs are launching a hi-tech screening programme in England in a fresh drive to identify thousands of people unaware they have the virus. The scheme, due to begin in the next few weeks, aims to help people living with hepatitis C get a life-saving diagnosis and access to treatment before it is too late. The NHS will identify people who may have the virus by using AI to scan health records for a number of key risk factors, such as historical blood transfusions or an HIV diagnosis. Anyone identified through the new screening process will be invited for a review by their GP and, if appropriate, further screening for hepatitis C. Those who test positive for the virus will be offered treatment available after NHS England struck a deal with three major pharmaceutical companies. Prof Graham Foster, national clinical chair for NHS England’s hepatitis C elimination programmes, said the scheme “marks a significant step forward” in the fight to eliminate the virus before 2030. It will “use new software to identify and test patients most at risk from the virus – potentially saving thousands of lives”, he added. Read full story Source: The Guardian, 31 July 2022
  19. News Article
    A call to NHS 111 was abandoned every 10 seconds between 2020 and 2021, figures show. Millions of callers to the helpline hung up at a time when demand for the NHS was at its highest. In 2020, 2,490,663 calls were abandoned, while in 2021 this figure increased to 3,531,186. And 1,174,159 gave up on the line from January to May this year. Callers in Devon take an average of 11 minutes to get through to the NHS 111 service, according to Liberal Democrat research. Daisy Cooper, Lib Dem spokeswoman for health and social care, said: "Ambulance services are being stretched to breaking point, hospitals are reaching full capacity and now people cannot get through to NHS 111. We have called on this government time and time again to get a grip on this issue by recruiting more NHS 111 call handlers now." "The longer they delay, the longer they are leaving people in pain and distress." Helen Hughes, of the Patient Safety Learning charity, said: "These figures represent a serious safety concern. Each call is a potential missed opportunity for patients to receive timely medical advice that may prevent future harm." "With the ongoing severe pressures faced by ambulance services and hospitals this summer, patients are increasingly being signposted to NHS 111 for advice on non-life threatening conditions." "However, it can only relieve the pressure on other areas of the health service if NHS 111 has the capacity and resources to meet rising demand. The NHS leadership needs to urgently assess the reasons for this high number of abandoned calls." Read full story Source: Express, 31 July 2022
  20. News Article
    Three former health secretaries have called on the government to urgently pay compensation to victims of the contaminated blood scandal. The chairman of the public inquiry into the scandal, Sir Brian Langstaff, has recommended that each victim should receive a provisional sum of £100,000. One woman who developed hepatitis C from infected blood told the BBC the news was "incredibly significant". The government has said it will urgently consider any recommendations. Former health secretaries Andy Burnham, Jeremy Hunt and Matt Hancock told the BBC it was important to act quickly because the life expectancy of many victims had been shortened by infections they had contracted. A lawyer representing about 15,000 claimants also argued that victims should receive compensation "immediately". Des Collins said payment must be made within "days or weeks", and he would step up pressure from Monday. Read full story Source: BBC News, 31 August 2022
  21. Content Article
    Perioperative practitioners in the UK are universally concerned about the risk surgical smoke plume poses to their health. Yet less than a fifth are aware of any policy being in place to manage this risk within their organisation. The majority of hospitals have plume evacuation equipment in place, but it is only used in the minority of surgical procedures. Almost three-quarters of theatre staff have experienced symptoms associated with exposure to surgical smoke plume. But these symptoms are rarely reported and, when they are, no action is generally taken. These are the findings of a new report published by the Surgical Plume Alliance (SPA), a joint advocacy initiative between the Association for Perioperative Practice (AfPP) and the International Council on Surgical Plume (ICSP). They aimed to gain a greater understanding of the awareness levels, training, management and policy surrounding surgical smoke plume in the UK.
  22. Content Article
    This report examines the approaches and key decisions taken by UK governments during the pandemic and the public health measures they introduced. It assesses whether these choices were timely, appropriate, and proportionate to deal with the threat and impact of COVID-19.
  23. Content Article
    Thrombectomy is a game-changing treatment for stroke. It changes the course of recovery from stroke in an instant, significantly reducing the chance of disabilities like paralysis, visual impairment and communication difficulties. It is also extremely cost-effective. Rolling out thrombectomy fully could save the UK £73 million a year, by reducing demand for rehabilitation and community support services.  But thrombectomy isn’t currently available for everyone who needs it (~10% of all stroke patients). The treatment is subject to a postcode lottery and in 2020/21, nearly 80% (5,889) of patients in England who needed a thrombectomy missed out. This report from the Stroke Assoication features some of the amazing people working tirelessly to improve outcomes for stroke patients, under challenging circumstances and often at a personal cost. And most importantly, it shows how truly life-changing thrombectomy can be for patients. The Stroke Association hopes this report will galvanise action at government and ICS levels that will benefit both stroke patients and professionals. They must urgently secure access to a 24/7 thrombectomy service, for every stroke patient who needs.
  24. Event
    The COVID-19 pandemic has profoundly impacted nearly all countries’ health systems and diminished their capability to provide safe health care, specifically due to errors, harm and delays in diagnosis, treatment and care management. “Implications of the COVID-19 pandemic for patient safety: a rapid review” emphasises the high risk of avoidable harm to patients, health workers, and the general public, and exposes a range of safety gaps across all core components of health systems at all levels. The disruptive and transformative impacts of the pandemic have confirmed patient safety as a critical health system issue and a global public health concern. The objectives of the WHO event are : provide an overview of implications of the COVID-19 pandemic for patients, health workers, and the general public highlight importance of managing risks and addressing avoidable harm in a pandemic situation discuss implications of the pandemic for patient safety within broader context of preparedness, response and recovery lay the foundation for follow-up work around generating more robust evidence and supporting countries in their efforts to build resilient and safer health care systems. Register
  25. News Article
    Startling numbers from around the world give grim statistical support for the argument that healthcare quality has not only stalled, but is in worrying retreat. Nearly 15 million deaths have been attributed to Covid-19 worldwide. All countries have seen waiting times increase and deaths from cardiac conditions and cancer rise. Mental health problems have been exacerbated, while the frailty of some elderly care services has left families unsupported. The global workforce crisis has been exposed, health inequalities amplified, and life expectancy arrested. Government debt has soared, and livelihoods have been lost. In a new report, health systems leaders from across the world – including the UK, Australia, India, Singapore, Canada, the USA and Europe – raise the alarm. There has been a decline in the focus on quality by the leadership of health systems all over the world with an opportunity cost in terms of patient outcomes, safety issues and people’s experience of healthcare. How do we shift from firefighting to a focus on quality of care? Dr Mark Britnell, chair of the Beamtree Global Impact Committee report, makes a simple argument: the only way to reverse the retreat from quality is to march steadfastly towards it. Read full story (paywalled) Source: The Telegraph, 26 July 2022
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