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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    NHS England and the Care Quality Commission are becoming less understanding of the pressures on trusts, their leaders report, with one CEO complaining “the arrogance and bullying continues to get worse”. This is the finding of a new survey of trust chiefs, chairs and directors by NHS Providers, shared with HSJ and published in a new report on regulation today. It found two-thirds of trust leaders felt NHSE had a good understanding of “the pressures that NHS providers are facing” — down from 74% cent in a similar NHSP regulation survey in 2019, and 75% in 2018. NHSP found: “Leaders from the acute sector were much more likely to say regulators understood the pressure they were under than those from the mental health or community sectors.” One combined acute/community CEO said: “Not only have the number of requests increased but now they are coming from multiple levels, [integrated care system], regional and national.” Meanwhile, most respondents welcomed regulators’ proposed changes to their approach – for example, by the CQC to a “risk based” approach, and NHSE towards collaboration – but many indicated they did not feel these were being put into practice. Read full story (paywalled) Source: HSJ, 26 July 2022
  2. Content Article
    This research explores how the COVID-19 pandemic has changed the ways doctors make end-of-life decisions, particularly around Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR), treatment escalation and doctors’ views on the legalisation of euthanasia and physician-assisted suicide.
  3. Content Article
    Reducing hospital bed days is currently the ultimate currency in healthcare. Large amounts of money seem to increasingly be diverted from tried and tested workforces into new services, new jobs, and new technology in order to prevent patients being admitted to hospital. Some of these new ideas could work well, while others have the potential to be a catastrophe, but what unites them all is a focus on a single outcome: saving bed days in the acute hospital. But The NHS's single minded pursuit of admission avoidance risks ignoring other important outcomes, writes Alison Leary in this BMJ opinion piece.
  4. News Article
    Doctors are less likely to resuscitate the most seriously ill patients in the wake of the pandemic, a survey suggests. Covid-19 may have changed doctors’ decision-making regarding end of life, making them more willing not to resuscitate very sick or frail patients and raising the threshold for referral to intensive care, according to the results of the research published in the Journal of Medical Ethics. However, the pandemic has not changed their views on euthanasia and doctor-assisted dying, with about a third of respondents still strongly opposed to these policies, the survey responses reveal. The Covid-19 pandemic transformed many aspects of clinical medicine, including end-of-life care, prompted by millions more patients than usual requiring it around the world, say the researchers. In respect of DNACPR, the decision not to attempt to restart a patient’s heart when it or breathing stops, more than half the respondents were more willing to do this than they had been previously. Asked about the contributory factors, the most frequently cited were: “likely futility of CPR” (88% pre-pandemic, 91% now); coexisting conditions (89% both pre-pandemic and now); and patient wishes (83.5% pre-pandemic, 80.5% now). Advance care plans and “quality of life” after resuscitation were also commonly cited. Read full story Source: The Guardian, 25 July 2022
  5. News Article
    The NHS has broken its “fundamental promise” to the public that life-saving emergency care will be available when they need it, a top NHS doctor has said, as ambulances continue to lose tens of thousands of hours waiting outside hospitals. Katherine Henderson, the president of the Royal College of Emergency Medicine, said that what she described as the fundamental promise of the NHS to provide an ambulance in a real emergency has been “broken”. Her comments come as the West Midlands Ambulance Service (WMAS) University NHS Trust predicted it would lose 48,000 ambulance hours waiting outside A&E departments in July. This would make it the worst month on record. In papers published on Thursday, WMAS said the impact of handover delays means that patients are waiting longer than needed for an emergency response, including patients in category one, which includes those needing immediate life-saving care. It added: “This means that patients who are immediately time-critical medical emergencies do not get the response they need and may suffer significant harm or death.” Read full story Source: The Independent, 26 July 2022
  6. News Article
    Women have spoken to the BBC about the "nightmare" of giving birth during the restrictions imposed because of Covid. The London Assembly was told a de facto maternity ward ban on partners meant new mums often got very little support. Campaign group Pregnant Then Screwed said elective Caesareans spiked, as women tried to find a way to have their partner by their side. Patient care also suffered as maternity units struggled with what a midwifery group said was a 40% staff absence. A London Assembly health committee review of Covid pandemic pregnancy care has heard that more than three-quarters of the some 110,000 women who gave birth in the capital in 2020 were believed to have done so without their partner's support. Joeli Brearley, director of Pregnant then Screwed, said elective Caesarean rates increased from 15% to 24%: "Women were requesting severe surgery simply so their partner could be there." Suzanne Tyler, from the Royal College of Midwives, agreed that London hospitals were badly affected by staff shortages. "At its worst, staffing was 40% down," she said. "The babies didn't stop coming during Covid but services did have to be rationalised." Dr Tyler, who said the pandemic "ended up pitting midwives against women", criticised "confusing... contradictory" advice from the government and NHS England that "kept changing". Read full story Source: BBC News, 26 July 2022
  7. News Article
    NHS England and local leaders must urgently develop a coherent ‘operating model’ for the era of integrated care systems (ICS) or see the reforms fail, leading trust chief executives have told HSJ. Despite ICSs formally launching on 1 July, the chiefs said there was still no clarity about how the service would be supported and held to account as the Health and Care Act reforms are rolled out and the stuttering Covid recovery continues. The CEOs were speaking at a roundtable to mark the publication of HSJ's annual ranking of the NHS’s “top 50 trust chief executives”. NHSE has been working on a new operating model since last year. It has confirmed it plans to keep its seven separate regional teams, and has recently indicated national programmes will be curbed as part of reductions to central staffing. Caroline Clarke, the chief executive of north London’s Royal Free group of trusts, said: “What’s unclear to me is, what the operating model is for [the] whole NHS? What is NHSE going to do… what’s expected of the regions and the ICSs… is the performance management line [for providers] going to go all the way through the ICS?” Ms Clarke said she recognised “some kind of regional infrastructure” was needed and that the existing set-up made sense in widely recognised areas such as London and other “urban” conurbations. But she added: “Are [regions] just going to be aggregating features of the NHS, or are they actually going to have a kind of intent to them?” Ms Clarke said she was “hung up” on getting an effective operating model because, without it, there was an increased chance NHSE staff would “get in the way and stop us making decisions”. Read full story (paywalled) Source: HSJ, 25 July 2022
  8. Content Article
    The House of Commons Health and Social Care Select Committee has published a report highlighting the current health and social care workforce crisis in England.  The 'Workforce: recruitment, training and retention' report, which calls for a robust workforce strategy, states that within the NHS in England there’s a shortage of over 50,000 nurses and midwives, while in April this year hospital waiting lists reached an all-time high of almost 6.5 million. 
  9. News Article
    Five wards at Scotland's largest hospital had to operate with one registered nurse on duty each. Staff at the Queen Elizabeth University Hospital in Glasgow experienced the shortage on Monday night. It is an example of the severe pressure affecting health services across the country, which has intensified due to the Covid-19 pandemic. Greater Glasgow and Clyde health board said nurses were supported by a number of other staff. Originally reported in the Daily Record, the shortage was described to staff in an email sent on Monday afternoon. The email said nurse staffing levels across medicine were critical, despite attempts to seek support from bank or agency workers. It said admin staff had been asked to stay on to offer support including answering phones and door buzzers for the rest of the week. As well as staffing problems, the pandemic has caused more bed blocking in Scotland's hospitals and longer waits for both emergency and outpatient treatment. Norman Provan, associate director at the Royal College of Nursing Scotland said the shortage had an impact on patient safety as well as staff wellbeing - concerns that had been raised with the health board and the Scottish government. He added: "We're in this situation largely because of the failure of Scottish government to address the nursing workforce crisis, which has seen registered nurse vacancies reach a record high. "Urgent action is needed to protect patient safety, address staff shortages and demonstrate that the nursing workforce is valued as a safety critical profession." Read full story Source: BBC News, 24 July 2022
  10. News Article
    A lack of accountability is causing the quality of NHS services to crumble, according to some of the most respected trust chief executives. They said the problem arose from four factors: the lack of an operating model for how NHS England should oversee the service, confusion over what integrated care systems should be responsible for, the lack of clarity on which standards providers should be seeking to meet, and trust leaders not holding each other to account. The views were expressed at a roundtable to mark the publication of HSJ’s annual ranking of the NHS’s “top 50 trust chief executives”. The most strongly worded contribution came from Milton Keynes University Hospital Foundation Trust chief executive Joe Harrison. He told the roundtable: “I’m really concerned about where we are at as an NHS. I think we’re in danger of all sitting around the campfire singing ‘kumbaya’ as the Titanic sinks. “We are presiding over a failing NHS. There’s no question about it. And if we carry on like this, people have every right to say, ‘what on earth are we spending £150bn on?’” Read full story (paywalled) Source: HSJ, 25 July 2022
  11. News Article
    One of the NHS’s biggest hospital trusts has declared its cancer waiting list is now at an ‘unmanageable size’. Mid and South Essex Foundation Trust leaders set out the stark judgement in a paper for its July board meeting, held last week. The report said: “The 62-day [referral to treatment backlog as of 3 July] has increased for the second consecutive week to 1,055. “[The cancer patient tracking list] is getting bigger and has reached an unmanageable size. Referral rates have plateaued from March 2021 [but] treatment rates have not increased in line with PTL growth. “This points to a noisy PTL, where the hospital is extremely busy managing patients who do not have cancer.” The paper also said NHS England had recognised the trust’s 62-day cancer target needed to be delivered “in more realistic and achievable stages”. It highlighted particular concerns around a “serious” demand and capacity problem in its dermatology department which contributed to almost half of its 62-day backlog. The trust had 445 62-day RTT cancer breaches in dermatology alone in May, the latest data reported. Read full story (paywalled) Source: HSJ, 22 July 2022
  12. News Article
    Maternity failings continue to account for the majority of billions of pounds spent by the NHS on clinical negligence claims, as an NHS body warns of the “devastating” consequences of poor care. Two-thirds of the £13bn spent by the NHS in 2021-21 in respect of negligence claims was related to maternity care, according to new data. A report released by NHS Resolution said it was “a stark reminder that although the NHS remains one of the safest healthcare systems in the world within which to give birth, avoidable errors within maternity can have devastating consequences for the child, mother and wider family, as well as the NHS staff involved.” According to the figures, 1,243 maternity-related negligence claims were reported to the NHS in 2021-22, up from 1,571 in the previous year. The data also shows that 200 claims relating to cerebral palsy or brain damage were received in 2021-22 – a decrease from the previous year, in which there were 250. The organisation said that the growth in obstetrics claims over the past three years was due to trusts reporting cases of cerebral palsy and brain damage earlier through its early notification scheme, which was launched in 2017. Read full story Source: The Independent, 24 July 2022
  13. News Article
    The large number of unfilled NHS job vacancies is posing a serious risk to patient safety, a report by MPs says. It found England is now short of 12,000 hospital doctors and more than 50,000 nurses and midwives, calling this the worst workforce crisis in NHS history. It said a reluctance to decisively plug the staffing gap could threaten plans to tackle the Covid treatment backlog. The government said the workforce is growing and NHS England is drawing up long-term plans to recruit more staff. Former Health Secretary Jeremy Hunt, who chairs the Commons health and social care select committee that produced the report, said tackling the shortage must be a "top priority" for the new prime minister when they take over in September. "Persistent understaffing in the NHS poses a serious risk to staff and patient safety, a situation compounded by the absence of a long-term plan by the government to tackle it," he said. It said conditions were "regrettably worse" in social care, with 95% of care providers struggling to hire staff and 75% finding it difficult to retain existing workers. "Without the creation of meaningful professional development structures, and better contracts with improved pay and training, social care will remain a career of limited attraction, even when it is desperately needed," the report said. Read full story Source: BBC News, 25 July 2022
  14. Content Article
    The National Guardian’s Office has published its latest annual speaking up data, which summarises the themes and learning from the speaking up data shared by Freedom to Speak Up guardians.
  15. Content Article
    Is good-quality health care being provided for women in prison? As the government proceeds with plans to build 500 more prison places for women, this new Nuffield Trust analysis uses HES data to look at women prisoners' use of hospital services, finding that they face a series of challenges and risks in prison because of barriers to accessing health and care services.
  16. Content Article
    Slides on preventing catheter-associated urinary tract infection (CAUTI) presented at a Safer Healthcare and Biosafety Network meeting. The session aimed to: Provide a brief overview of CAUTI as a clinical problem. Summarise evidence for key infection prevention practices to reduce CAUTI. Consider how to implement improvements to support best practice and promote safer care.
  17. Content Article
    'The Staff Support Guide: a good practice resource following serious patient harm' was launched at Parliamentary reception on 29 June 2022. View the presentation about it from Patient Safety Learning and the Safer Healthcare Biosafety Network at the recent Network meeting.
  18. Content Article
    Effective incident investigation is an integral part of the provision of a safe blood transfusion service, with the aim to prevent recurrence of adverse events and harm to patients. Determining how an incident has taken place allows understanding of the gaps or failures within the system and identification of effective corrective and preventive measures that can be implemented to reduce risk of recurrence. Consideration of human factors supports a more sophisticated understanding of the factors that cause incidents, optimising human performance through better understanding of human behaviour and the factors that influence this behaviour, thus improving patient safety. 
  19. Content Article
    Infographic highlighting statistics on ethnic health inequalities in the UK.
  20. Content Article
    The science behind the symptoms of Long Covid are explained in this infographic from docdroid.
  21. News Article
    Medical students are using hologram patients to hone their skills with life-like training scenarios. The project at Addenbrooke’s Hospital in Cambridge is the first in the world to use the mixed reality technology in this way. Students wear Microsoft HoloLens headsets that let them interact with the patient while still being able to see each other. Lecturers are able to alter the patient’s response, make observations and add complications to the scenario. It enables realistic and immersive safe-to-fail training which can be delivered remotely as well as in person. The first module, covering respiratory conditions and emergencies, has already been launched and more are planned around cardiology and neurology. The HoloScenarios system is being developed by Cambridge University Hospitals NHS Foundation Trust, in partnership with the University of Cambridge and US-based tech firm GigXR. Consultant anaesthetist Dr Arun Gupta, who is leading the project in Cambridge, said: “Mixed reality is increasingly recognised as a useful method of simulator training. As institutions scale procurement, the demand for platforms that offer utility and ease of mixed reality learning management is rapidly expanding" Read full story Source: CIEHF, 21 July 2022
  22. Content Article
    After 12 years of brutal service, Neil Barnard, an NHS emergency medicine consultant, is leaving his NHS post to work abroad. His decision to leave is driven by financial and personal reasons. More than anything, he says he's tired and has little more left to give to the NHS. 
  23. Content Article
    This article in the Nursing Times Long Covid series discusses how nurses are at high occupational risk of Long Covid and how best to support them.
  24. Event
    Join this Royal Society of Medicine conference to learn some of the key medico-legal issues that impact upon GPs/primary care. The overarching aim is to improve patient safety in both primary and secondary care via learning from incidents and better understanding the indemnity provisions in place for GPs/primary care and how that feeds back into learning. The aim of this meeting is to review and promote an understanding of recent legal and regulatory developments, with a specific emphasis on inquests, clinical negligence and incidents in the primary care sector, and their impact upon patient safety. Additionally, we will also discuss issues that those in secondary care should also be aware of. Register
  25. News Article
    Medicines and medical devices valued at over £850,000, totalling more than 285,000 items, have been seized by officers from the UK’s Medicines and Healthcare products Regulatory Agency (MHRA) as part of a global operation to tackle the illegal sale of medical products, with UK seizures estimated to be worth around 9% of the global total. In the UK, 48 social media accounts unlawfully offering to supply medicines were also shut down. Officers from the MHRA Criminal Enforcement Unit searched five premises in the West Midlands and London, with two suspects arrested. During the global week of action coordinated by Interpol, which ran from 23-30 June, this year’s ‘Operation Pangea’ saw countries across the world joining forces to seize non-compliant medical products. The operation also involved the arrests of several suspected organised criminals. In the UK, anti-depressants, erectile dysfunction tablets, painkillers, anabolic steroids and slimming pills were among the medicines seized. Andy Morling, Deputy Director (Criminal Enforcement) at the MHRA, said: "Criminals illegally trading in medicines and medical devices are not only breaking the law but they also have no regard for your health. Unlicensed medicines and non-compliant medical devices pose serious risk to public health as both their safety and efficacy can be compromised." Read press release Source: MHRA, 20 July 2022
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