Jump to content
 View Profile  See their activity

  • Posts

    11,589

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

Everything posted by Patient Safety Learning

  1. News Article
    The recent publication of the Fuller Stocktake report sets out a new vision for the role of primary care in integrated care systems. With primary care the bedrock of the NHS and at “the heart of communities”, the paper’s recommendation to similarly establish it at the centre of new ICS systems and foster greater collaboration is a welcome one that has been greeted positively in many quarters. However, a key priority underpinning many of the recommendations made is the need to create sustainable primary care for the future. Within this, there is a challenge to tackle “inadequate access to urgent care” which the report argues is having a direct impact on general practice’s ability to provide continuity of care to patients who need it most as well as overall primary care capacity. Referred to as being two sides of the same coin, this stark recognition of current workload and workforce challenges in general practice alongside their wider contributing factors is both timely and welcome. Read full story (paywalled) Source: HSJ, 27 July 2022
  2. Event
    This Westminster conference discusses the Government’s Women’s Health Strategy for England and the next steps for implementing ambitions in the context of a new Prime Minister. Delegates will look at the priorities for improving women’s health outcomes, service delivery and workforce education. Areas for discussion include: the strategy - scope and emphasis - implementation - the leadership and accountability to achieve progress service development - improving diagnosis - integration - tackling variation in access and other areas of inequality stigma - improvement of the first points of contact in primary care sexual and reproductive health - care and support across the life cycle - diagnosis rates - accessibility of services and information - patient-centred approaches research - areas of focus for women’s health - improving the data and the evidence base inequalities - tackling disparities in health outcomes - building a responsive environment for women’. Register
  3. News Article
    A leading colorectal surgeon whose former employer, North Bristol NHS Trust, faces negligence claims from dozens of his ex-patients has failed in his bid to keep legal action he is taking against the trust a secret. A review by the trust found that 203 women on whom the surgeon Tony Dixon performed pelvic mesh procedures between 2007 and 2017 came to harm. The trust faces legal claims from many of them. Trust board members were told in May that the trust had notified the 203 women that “although their laparoscopic ventral mesh rectopexy operation was carried out satisfactorily, they should have been offered alternative treatments before proceeding to surgery,” and that those patients were defined as suffering “harm.” Dixon sued the trust in the High Court to try to stop it releasing two documents to solicitors acting for ex-patients, as part of the disclosure process in litigation. Read full story (paywalled) Source: BMJ, 27 July 2022
  4. News Article
    County Durham and Darlington NHS Foundation Trust has created and implemented an artificial intelligence (AI) model to protect patients from acute kidney injury (AKI). The trust’s AI-driven model helps healthcare staff to identify patients who are at risk from AKI and to swiftly respond with treatment. The technology uses risk stratification digital tools that staff are able to access through an app. These are combined with care processes developed at the trust and which involve a new specialist nurse team, preventive specialist intervention, assessment and follow-up. Its implementation at County Durham and Darlington has led to a reduction in both hospital-acquired and community AKI. Overall, the incidence of AKI within the trust fell from 6.5% between March and May 2020, to 3.8% during the same period in 2021. The most significant reduction was seen in hospital-acquired AKI – which fell by more than 80%. Jeremy Cundall, medical director for County Durham and Darlington NHS Foundation Trust and executive lead for the project, said: “The partnership has resulted in patients being detected earlier – preventing AKI from occurring or mitigating the worsening of existing AKI. Accordingly, patients have been more effectively triaged to the right pathways of care including referral and transfer to tertiary renal units where appropriate.” Claire Stocks, early detection, resuscitation and mortality lead nurse for County Durham and Darlington NHS Foundation Trust, said: “This work has been a project very much about using collaborative partnerships to enhance patient safety and quality. An idea that was developed in a ‘cupboard conversation’ is now a fully operational specialist nurse service. Utilising digital innovations supports rapid triage, early detection and treatment to improve outcomes.” In addition to the improvements in patient safety, the technology has delivered cost savings for the trust too. County Durham and Darlington saved more than £2million in direct costs from reductions in AKI incidence. The improved transfer of patients has also released ICU capacity, vital at a time when the NHS is dealing with a growing national backlog for elective surgery. Read full story Source: Digital Health, 27 July 2022
  5. News Article
    Almost 75 years since its foundation, the NHS is struggling with delays caused by the coronavirus pandemic and the “greatest workforce crisis” in its history. A report from MPs on the health committee this week showed 105,000 vacancies for doctors, nurses and midwives, as thousands quit owing to burnout, bullying, pension rules and low pay. Jeremy Hunt, the committee’s chairman, said that the “persistent understaffing in the NHS poses a serious risk to staff and patient safety”. Lawyers warned that the crisis risked increasing the number of negligence claims. Spending on claims by NHS Resolution rose to £2.5 billion in 2021-22 compared with £2.3 billion in the previous year, according to its annual report published last week. The bill increased despite initiatives to cut the number of cases going to court and foster greater collaboration with claimant lawyers. Claimant lawyers welcomed NHS Resolution’s more collaborative approach and desire to resolve cases sooner. They argued, however, that the defensive culture remained and suggested there should be a greater focus on patient safety and learning from mistakes. John McQuater, president of the Association of Personal Injury Lawyers, said that NHS Resolution’s denials and delays meant that injured patients had to turn to lawyers to find answers. He said that earlier investigation into patient safety incidents and earlier admissions of liability by NHS trusts would speed up the system, cutting costs and human misery. Read full story (paywalled) Source: The Times, 28 July 2022
  6. News Article
    The NHS’s only gender identity clinic for children has been found to be neither “safe nor viable” and is set to be replaced by regional hubs. A damning report into gender identity services run by the Tavistock and Portman Foundation Trust has found that the model is putting children at “considerable risk”. An interim report by Dr Hilary Cass said that children and young people are being subjected to “lengthy” waits for access to gender dysphoria services, and are not receiving support during this time. The report said a “fundamentally different” service model that can provide timely and appropriate care for children is needed, and recommended that the NHS launch local specialist centres. Her full report is due to be published next year, but has so far warned that the long waiting lists for gender-questioning children and young people are “unacceptable”. The review said it was not yet able to provide recommendations on the use of puberty blockers and feminising or masculinising hormones, due to gaps in the evidence. A report from safety watchdog the Healthcare Safety Investigation Branch in April warned that CAMHS (Children and Adolescent Mental Health Services) had been forced to “hold the risk” while caring for children who are waiting to access specialist gender-dysphoria (GID) services. It added: “There is a lack of capacity and capability to ensure proactive risk assessment of the health of patients waiting on the GIDS waiting list.” Read full story Source: The Independent, 28 July 2022
  7. News Article
    Patients experiencing a mental health crisis were kept in a ‘short stay area’ of an emergency department for up to three weeks, a Care Quality Commission (CQC) report has revealed. The patients were in what the CQC described as a “short stay area” of the ED at the Royal Sussex County Hospital in Brighton. It is an area with no natural light, no TV or radio and only a toilet and washbasin, with a shower available on a neighbouring ward, the CQC said. The patients were reviewed daily by a mental health liaison team from another trust while they waited for a mental health bed to be found. The CQC report said staff reported the longest stay was up to three weeks, while trust data showed the average length of stay was 52 hours. It said the urgent and emergency services at the hospital – part of University Hospitals Sussex Foundation Trust which is rated “outstanding” overall by the regulator – “did not fully meet the needs of the local population”. Read full story (paywalled) Source: HSJ, 29 July 2022
  8. News Article
    Bullying and harassment allegations made against leaders of the organisation that supplies blood to the NHS have prompted a Care Quality Commission (CQC) review, with staff claiming poor culture has exacerbated the crisis around low blood stocks. HSJ has learned whistleblowers at NHS Blood and Transplant raised concerns with the CQC. As a result, the regulator has been carrying out a review of the organisation’s leadership. Several current and former staff, who wished to remain anonymous, told HSJ there are widespread concerns about the organisation’s culture, which they claim has enabled bullying and harassment from senior employees, including some racist behaviours. They said the culture has resulted in a significant number of staff being absent due to stress and anxiety, which alongside the latest wave of coronavirus, has contributed to an ongoing staffing crisis. Read full story (paywalled) Source: HSJ, 28 July 2022
  9. News Article
    NHS leaders across England say staffing gaps and a lack of capacity in social care are putting the care and safety of patients in the NHS at risk. Almost 250 NHS leaders responding to an NHS Confederation survey say that patients are being delayed in hospital much longer than they should, with the knock-on impact resulting in higher demand on A&E departments and longer ambulance response times. More than 9 in 10 NHS leaders warn of a social care workforce crisis in their area which they expect will get worse this winter. Nearly all NHS leaders say the lack of capacity in social care is putting the care and safety of patients at risk. More than four in five warn that the absence of care packages for people to be able to return home or be moved into a care home is the main reason why medically fit patients are stuck in hospital longer than they should be. Almost all NHS leaders say that the most impactful solution would be better pay for social care staff and want the Government to increase investment in social care as a priority. An acute trust executive director in the South West accused the Government of presiding over a “national scandal.” “If the social care capacity shortfall was solved then we would not be holding ambulances at all, we would have almost no problems with elective recovery and our emergency departments would not be crowded and unsafe,” they said. Another acute trust chair in the East of England added: “The result of using nearly 20 per cent of our beds for patients who are medically fit but need packages of care to return home is an overcrowded A&E, twelve-hour trolley waits and much delayed ambulance handover times. The connection is very clear to us…Until we find a solution to social care staffing and funding, the situation can only get worse.” Commenting on the survey results Lord Victor Adebowale, chair of the NHS Confederation, said: “Decades of delay and inertia have left social care services chronically underfunded and in desperate need of more support. “NHS leaders stand alongside their sister services in social care in wanting a rescue package for the sector. They are sounding the alarm and sending a clear message to Government that the social care system has not been ‘fixed’." Read full story Source: NHS Confederation, 28 July 2022
  10. News Article
    Women going through menopause should be given greater rights and protection in the workplace, MPs say. The Women and Equalities Committee said a lack of support in the UK was pushing women out of work. The cross-party group wants menopause to become a protected characteristic like pregnancy, to give working women more rights. Caroline Nokes, who chairs the committee said: "Stigma, shame and dismissive cultures can, and must, be dismantled." The government, speaking on the issue for England as health issues is devolved to the national governments in Scotland, Wales and Northern Ireland, said the issue was a priority, highlighting it had recently appointed a women's health ambassador and set up a menopause taskforce to look into workplace support. Read full story Source: BBC News, 28 July 2022
  11. News Article
    A new report by the Stroke Association released today warns that, if the thrombectomy rate stays at 2020/21 levels, 47,112 stroke patients in England would miss out on the game changing acute stroke treatment, mechanical thrombectomy, over the length of the newly revised NHS Long Term Plan. This year, NHS England missed its original target to make mechanical thrombectomy available to all patients for whom it would benefit – only delivering to 28% of all suitable patients by December 20212. The Stroke Association’s ‘Saving Brains’ report calls for a 24/7 thrombectomy service, which could cost up to £400 million. But treating all suitable strokes with thrombectomy would save the NHS £73 million per year. Stroke professionals quoted in the report cite insufficient bi-plane suites, containing radiology equipment, as a barrier to a 24/7 service. The Stroke Association is calling for: The Treasury to provide urgent funding for thrombectomy in the Autumn Budget 2022, for infrastructure, equipment, workforce training and support, targeting both thrombectomy centres and referring stroke units. Department of Health and Social Care to develop a sustainable workforce plan to fill the gaps in qualified staff. NHS England to address challenges in transfer to and between hospitals in its upcoming Urgent & Emergency Care Plan. Putting innovation - such as artificial intelligence (AI) imaging software and video triage in ambulances - into practice. Juliet Bouverie, Chief Executive of the Stroke Association said: “Thrombectomy is a miracle treatment that pulls patients back from near-death and alleviates the worst effects of stroke. It’s shocking that so many patients are missing out and being saddled with unnecessary disability. Plus, the lack of understanding from government, the NHS and local health leaders about the brain saving potential thrombectomy is putting lives at risk. There are hard-working clinicians across the stroke pathway facing an uphill struggle to provide this treatment and it’s time they got the support they need to make this happen. It really is simple. Thrombectomy saves brains, saves money and changes lives; now is the time for real action, so that nobody has to live with avoidable disability ever again." Read full story Source: The Stroke Association, 28 July 2022
  12. News Article
    Former Health Secretary Jeremy Hunt has told a public inquiry institutions and the state can sometimes "close ranks around a lie". Giving evidence at the infected-blood inquiry, he said it could be seen as a "huge failing of democracy" that victims had waited so long for justice. At least 5,000 people contracted HIV or hepatitis C in the 1970s and 80s, after being given contaminated blood products and transfusions on the NHS. More than 2,400 have died as a result. Jenni Richards QC asked whether a 2012 briefing for new ministers in the health department - "almost certainly" not shown to Mr Hunt at the time - stating, under a heading "Key facts", hepatitis C and HIV (Human Immunodeficiency Virus) infection had been a problem in the 1970s and 80s, "before it was possible to screen donors and make products safer", suggested the contamination had been an "unavoidable problem". Mr Hunt, health secretary for six years until July 2018, replied: "I mean, that briefing is wrong and it shouldn't say that. "At the very least, ministers should be aware as politicians that this is contentious and disputed by families - but I'm afraid it tries to suggest the issue is closed when it is not." Read full story Source: BBC News, 27 July 2022
  13. News Article
    Hospital passports need to be more consistently used across the NHS to better support patients with communication difficulties, a learning disability nurse says. Support for patients with communication needs and learning disabilities, as well as the nurses caring for them, is often ‘inconsistent’, according to RCN professional lead for learning disabilities Jonathan Beebee. Coupled with the current system-wide pressure of patient backlogs and high staff vacancy rates it means patients often do not have their communication needs met. A hospital passport, which contains vital information about a patient’s health condition, learning disability and communication needs, would help address this, Mr Beebee told Nursing Standard. "There has got to be better consistency in how we are identifying people with communication needs, how they are getting flagged and how nurses are being pointed to that from the second that someone is admitted to the ward," he said. Mr Beebee says ensuring a standardised approach would improve patient experience and ultimately nurses’ relationship with patients. Read full story Source: Nursing Standard, 27 July 2022
  14. News Article
    Whistleblowing is still not ‘business as usual’ and leaders must take action after an unusual drop in the proportion of staff viewing their organisation as having a positive speak up culture, the national guardian for freedom to speak up has said. Speaking to HSJ, Jayne Chidgey-Clark highlighted some “really concerning” findings from the National Guardian’s Office’s most recent survey, both about speak up culture and the wellbeing of the freedom to speak up guardians. The NGO survey found a 10 percentage point drop in freedom to speak up guardians agreeing senior leaders supported workers to speak up, dropping from around 80% to 70% between 2020 and 2021. She also highlighted an increase in FTSU guardians reporting staff had experienced “detriment” for speaking up within their organisation. Ms Chidgey-Clark, a nurse by background who took up the role last December, said it was the first time the National Guardian’s Office had seen a drop on this question since the survey began in 2017, and that it also “chimed” with the latest NHS staff survey. She added: “Workers are saying the same thing, and that’s really concerning. And it will be even more concerning if we see a similar trend next year. It’s almost like an early warning sign to leaders." Read full story (paywalled) Source: HSJ, 28 July 2022
  15. Gallery Image
    Bupivacaine and sodium chloride
    Do we need a magnifying glass in every anaesthetic room? Only a matter of time until something bad happens...
  16. Gallery Image
    Sodium chloride and levobupivacaine
    Levobupivacaine is a local anaesthetic. Labelling very similar to the Sodium chloride.
  17. Event
    until
    The Patient Safety Incident Response Framework (PSIRF) will be published early August 2022, as a major piece of guidance on how NHS organisations respond to patient safety incidents, and ensure compassionate engagement with those affected. Secondary care providers will be asked to begin preparing to transition to PSIRF from September 2022. Preparation is expected to take 12 months with all organisations transitioning to PSIRF by August 2023. This webinar will be hosted on MS Teams Live to provide: An introduction to the Patient Safety Incident Response Framework and accompanying guidance An overview of the next steps for providers as they begin work to prepare to transition to the framework An outline of the six preparation phases over the next 12 months Details of resources and support to help providers prepare for PSIRF Opportunities to ask questions. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England National Patient Safety Team Lauren Mosley, Head of Patient Safety Implementation, NHS England National Patient Safety Team Register
  18. News Article
    The new health and social care secretary has asked officials to hastily organise several “hackathons” to try to address the crisis in ambulance performance. The first, which was instigated just last week, will take place tomorrow (28 July), and a second is planned for August, sources told HSJ. Messages from officials described the work as a “request from our new secretary of state” and explained the short notice by saying he was “pushing… quite strongly for something before the end of the month”. The aim is said to be to examine what is driving poor performance, and the Department of Health and Social Care is “particularly interested in understanding which factors reduce risk to patients”, according to one message seen by HSJ. Hackathons are short, time-limited collaborative design events, typically involving computer programmers and data scientists or analysts, which aim to result in working software or product on the chosen theme by the end. Read full story (paywalled) Source: HSJ, 27 July 2022
  19. Content Article
    Disabled people's voices need to be valued and prioritised in the planning and delivery of health and care services. This long read sets out the findings of research carried out by The King's Fund and Disability Rights UK into how disabled people are currently involved in health and care system design, and what good might look like.
  20. News Article
    A whistleblower has warned a London hospital is "literally in meltdown" after its IT system was knocked out during last week's heatwave. Operations at Guy's and St Thomas' Hospital in Lambeth were cancelled after its IT servers broke down in 40C (104F) temperatures on 19 July. A doctor told the BBC "poor planning" and "chronic underfunding" meant issues remained a week later. A spokesperson for the hospital said IT issues were "having an ongoing impact". Without a functioning IT system, staff have returned to paper notes, the doctor said. The anonymous whistleblower, who works as a doctor at Guy's and St Thomas', said this meant "we see very worrying results, but we don't know where the patients are so we spend ages tracking them down". "We cannot read any historical notes from patients. Names are being misspelt, so scans are not showing up. "Each morning, someone hand-delivers a stack of test results to the ward. In there, we received several patient results that don't belong to our ward," the doctor said. "If we don't recover our shared drives, we risk losing months of research data, if not years." Read full story Source: BBC News, 27 July 2022
  21. News Article
    The decades-old routine of visiting an NHS dentist for a six-month checkup is being scrapped across England and Wales for most adults as part of changes designed to address the dire lack of access to dental care for many people. Wales has announced that most adults now only need to see their dentist once a year, which the government in Cardiff says will free up NHS dentists’ time and allow them to take on more than 100,000 extra patients annually. The Labour-controlled Welsh government also hinted it wanted to recruit disillusioned dentists from England by offering chances to develop skills such as carrying out more complex surgery within their practices. Its announcement came after the UK government wrote to NHS dentists last week saying that under the first changes to the dental contract in 16 years, healthy people will only need a checkup every two years. It said this complied with guidance from the National Institute for Health and Care Excellence (Nice), which says dental teams should see patients for a checkup based on their health risk, which can be once every two years instead of every six months. Both governments claimed the moves would allow more people to find NHS care but dentists’ representatives in England and Wales described the changes as “tinkering” and “marginal tweaks”. Read full story Source: The Guardian, 27 July 2022
  22. News Article
    The NHS and the Treasury need to make a renewed commitment to increasing the number of patients who benefit from thrombectomy, the Stroke Association has said, as it revealed the service was dependent on just 106 doctors in England. New analysis due to be published by the charity later this week – and shared with HSJ – also found only a quarter of thrombectomy units are open 24 hours, seven days a week, with 42% only operating during office hours and Monday to Friday. Despite an NHS long-term plan target of treating 10% of strokes with a thrombectomy by this year, only 2.8% were benefitting in December 2021 – a smaller proportion than in the US or some other Western European nations. It means nearly 6,000 people who could benefit from thrombectomy are missing out, the charity has calculated. The Stroke Association’s report also highlighted large apparent regional variation in the share of stroke patients receiving the treatment — with London patients several times more likely to receive the treatment than elsewhere. Read full story (paywalled) Source: HSJ, 27 July 2022
  23. News Article
    A change in pre-eclampsia testing for pregnant women could help save lives. The potentially-fatal condition affects around 6% of women, often during the second half of pregnancy. The National Institute for Clinical Excellence (NICE) had recommended a test that could only rule out the condition, but now recommends more accurate tests that can diagnose cases. The Welsh government welcomed the new guidance, but said routine screening had not been recommended. Jeanette Kusel, director for scientific advice at NICE, said: "These tests represent a step change in the management and treatment of pre eclampsia. "New evidence presented to the committee shows that these tests can help successfully diagnose pre eclampsia, alongside clinical information for decision-making, rather than just rule it out. "This is extremely valuable to doctors and expectant mothers as now they can have increased confidence in their treatment plans and preparing for a safe birth" Eleri Wyn Foxhall, 32, from Penygroes in Gwynedd had pre-eclampsia in 2020. She welcomes the move, but called for women to be tested routinely. She believes there is a general "lack of information" about pre-eclampsia, and wants more work to be done on early detection. Read full story Source: BBC News, 26 July 2022
  24. News Article
    UK experts believe they have identified the cause of the recent spate of mysterious liver problems affecting young children around the world. Investigations suggest two common viruses made a comeback after pandemic lockdowns ended - and triggered the rare but very serious hepatitis cases. More than 1,000 children - many under the age of five - in 35 countries are thought to have been affected. Some, including 12 in the UK, have needed a lifesaving liver transplant. The two teams of researchers, from London and Glasgow, say infants exposed later than normal - because of Covid restrictions - missed out on some early immunity to an adenovirus, which normally causes colds and stomach upsets, and adeno-associated virus 2. Noah, three, who lives in Chelmsford, Essex, needed an urgent liver transplant after becoming dangerously ill with hepatitis. His mother, Rebecca Cameron-McIntosh, says the experience has been devastating. "He'd previously had nothing wrong with him," she says. "And for it to suddenly go so quickly. I think that's what kind of took us by surprise. "We've just assumed it was one little problem that will get easily sorted out - but actually it just kept on snowballing." Noah's recovery has been good - but he will need to take immunosuppressant drugs fo life, to stop his body rejecting the new liver he received. Rebecca says: "There is something really heartbreaking about that because you go along following the rules, do what you are supposed to do to protect people that are vulnerable and then, in some horrible roundabout way, your own child has become more vulnerable because you did what you were supposed to do." Read full story Source: BBC News, 26 July 2022
  25. Content Article
    This guidance is for Integrated Care Boards, NHS trusts, foundation trusts and NHS England. It supports effectively partnership working with people and communities to improve services and meet the public involvement legal duties.
×
×
  • Create New...