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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The emotion of the team is a sum-total of emotions and feelings that members of the team experience. Left unnoticed, unexpressed, and unattended, these emotions can grow toxic to harm relationships or grossly undermine team’s potential. Leaders have a choice of either noticing those emotions intentionally and intervening constructively when needed or just ignore the emotions to focus only on the outcomes and the process. Tuning into team emotions, fostering productive relationships, building trust, and a conducive environment within the team is the constant work of leadership.
  2. News Article
    Sajid Javid has resigned and been replaced by Steve Barclay as health and social care secretary. Mr Barclay, previously chief of staff to the prime minister, was reported as having been given the role on Tuesday evening. Mr Barclay said: “It is an honour to take up the position of Health and Social Care Secretary. Our NHS and social care staff have showed us time and again - throughout the pandemic and beyond - what it means to work with compassion and dedication to transform lives. This government is investing more than ever before in our NHS and care services to beat the Covid backlogs, recruit 50,000 more nurses, reform social care and ensure patients across the country can access the care they need.” Mr Barclay’s appointment came hours after Mr Javid — health secretary since June last year — announced his resignation, saying in a letter to Boris Johnson that he “can no longer, in good conscience, continue serving in this government” and that Mr Johnson has lost his confidence. Read full story (paywalled) Source: HSJ, 6 July 2022
  3. News Article
    NHS England has set trusts and systems a ‘100-day challenge’ to discharge more patients from hospital and free up beds before winter. David Sloman, chief operating officer of NHSE, has asked leaders of integrated care boards, acute and community trusts in a letter sent last week to adopt 10 “best practice initiatives” which he said “can make a significant difference in facilitating discharge and improving care for patients”. Trusts and systems have been given until 30 September to have a “full understanding” of the initiatives (listed below) and “infrastructure in place” to implement them. The initiatives include setting expected dates of discharge for patients within 48 hours of admission, “apply seven-day working” to discharge more patients at weekends, treat delayed discharge as “a potential harm event” and to manage workforces in community and social care services “to better match predicted patterns in demand”. Sir David has told regional and local leaders that a dedicated national NHSE team will set up “launch meetings” in each system, which will ensure there is “a focus on improving processes and performance around discharge”. Read full story (paywalled) Source: HSJ, 5 July 2022
  4. News Article
    A doctor who killed a mother-of-three when he botched a procedure during a routine appointment has been jailed. Dr Isyaka Mamman, now thought to be 85, admitted gross negligence manslaughter over the death of Shahida Parveen, 48, at the Royal Oldham Hospital in 2018. He used the wrong needle and inserted it in the wrong place, piercing the sac holding Mrs Parveen's heart. Mrs Justice Yip at Manchester Crown Court said Mrs Parveen's death was his fault and sentenced him to three years. She also criticised the NHS trust, pointing to the fact that Mamman had both lied about his age and had been involved in two critical incidents similar to that which led to Mrs Parveen's death. The court heard Mrs Parveen attended Royal Oldham Hospital on 3 September, 2018, to give a bone marrow sample. This is usually taken from the hip bone but, after failing in his first attempt, Mamman tried to instead take it from her sternum. This was a "highly dangerous" procedure, the court was told, and one which had led to another of Mamman's patients being permanently disabled three years earlier. Read full story Source: BBC News, 5 July 2022
  5. News Article
    There are plans for a major overhaul of how people are rescued from car wrecks amid growing evidence that current methods where people wait to be cut free may be harmful. Last year there were 127,967 casualties and 1,560 deaths in England caused by motor vehicle collisions. During the same period, more than 7,000 patients needed to helped out of the vehicle through a process known as extrication, where rescue crews use “Jaws of Life” and other tools to pry apart the wreckage, and then carefully lift people out. “Since at least the 1980s, firefighters have been trained with movement minimisation as the absolute paradigm,” said Dr Tim Nutbeam, an NHS emergency medicine consultant, and medical lead for the Devon air ambulance. “They’ve been told that one millimetre of movement could turn someone into a wheelchair user, so will often disassemble the car around the patient, to avoid movement of the neck.” Yet, doing so takes time – 30 minutes on average – and if that person has another serious injury, such as a head, chest, or abdominal injury, every minute counts. Nutbeam began researching the issue and discovered that trapped patients were almost twice as likely to die as those who were rapidly freed from the wreckage. Further, that the prevalence of spinal injuries among such patients was, in fact, extremely low – just 0.7% – and in around half of these cases, they had other serious injuries needing urgent medical attention. “Our absolute focus on movement minimisation works for maybe 0.3% of patients, but it extends the entrapment time for 99.7% of them,” Nutbeam said. “Potentially hundreds of people in this country have died as a result of extended entrapment times, and if you multiply that worldwide, it’s many, many people.” Read full story Source: The Guardian, 6 July 2022
  6. News Article
    A woman was kept in police custody for 36 hours after having a stillbirth because of suspicions she had an abortion after the legal cut-off point, it has been claimed. UK abortion providers, who supported the woman, denied she had flouted the legal deadline and warned the treatment she endured “should be unthinkable in a civilised society”, with “no conceivable” public interest in holding her. They added that the woman has been under investigation for a year and a half, but still not charged with any crime. Jonathan Lord, medical director of MSI Reproductive Choices, one of the UK’s leading abortion providers, told The Independent the woman unexpectedly delivered a stillborn foetus at home that was about 24 weeks old. Dr Lord, the co-chair of the British Society of Abortion Care Providers, who shared the woman’s story with The Independent, said: “She was shocked to give birth due to not knowing how far along pregnant she was. She was admitted to hospital. “Because healthcare colleagues were suspicious, and knew she had been in touch with us, an abortion provider, as she told them, they suspected her of having an illegal abortion and called the police. But she wasn’t over the limit for a legal abortion. Dr Lord said the experience of having an “extraordinarily unexpected” stillbirth before being taken into police custody during lockdown was “traumatic” and “distressing” for the woman. Read full story Source: The Independent, 5 July 2022
  7. News Article
    The NHS plans to use drones to fly chemotherapy drugs to cancer patients in England to avoid the need for long journeys to collect them. The devices will transport doses from Portsmouth to the Isle of Wight in a trial that, if successful, will lead to drones being used for similar drops elsewhere. They will take 30 minutes to travel acrss the Solent, which will save patients on the island a three to four-hour round trip by ferry or hovercraft. On Tuesday, Amanda Pritchard, NHS England’s chief executive, unveiled the move to help mark the 74th anniversary of the health service’s creation by the postwar Labour government. “Delivering chemo by drone is another extraordinary development for cancer patients and shows how the NHS will stop at nothing to ensure people get the treatment they need as promptly as possible, while also cutting costs and carbon emissions,” she said. Read full story Source: The Guardian, 5 July 2022
  8. Content Article
    In this editorial, published in the British Journal of Hospital Medicine, Dr Paul Grime reviews the report 'Mind the implementation Gap: The persistence of avoidable harm in the NHS', which calls on the government, parliamentarians and NHS leads to take action to address the underlying causes of avoidable harm in healthcare.
  9. News Article
    It would be “sensible” for hospitals to reintroduce mandatory mask-wearing, the chair of the Joint Committee on Vaccination and Immunisation has said, as several trusts in England and Wales announced the move. When NHS rules on wearing masks in England were dropped on 10 June, local health bodies were given the power to draft their own policies. Their guidance, however, is no longer legally enforceable. Figures from NHS England show there were about 10,658 patients hospitalised with coronavirus on Monday. Infections have doubled in a fortnight across England – with about 1,000 patients being admitted with the virus each day. Prof Andrew Pollard, who is also the director of the Oxford Vaccine Group, which developed the AstraZeneca jab, said there were an “extraordinary” number of cases at the moment. “I certainly know more people now who have had Covid than at any time in the past,” he told the BBC Radio 4’s Today programme. “Because there’s so much in the community, anything we can do in our hospitals to reduce the potential outbreaks make sense and so the mandatory mask wearing in hospitals is very sensible policy,” he added. Read full story Source: The Guardian, 5 July 2022
  10. Content Article
    The Indian Liver Patient Dataset (ILPD) is used extensively to create algorithms that predict liver disease. Given the existing research describing demographic inequities in liver disease diagnosis and management, these algorithms require scrutiny for potential biases. Isabel Straw and Honghan Wu address this overlooked issue by investigating ILPD models for sex bias. They demonstrated a sex disparity that exists in published ILPD classifiers. In practice, the higher false negative rate for females would manifest as increased rates of missed diagnosis for female patients and a consequent lack of appropriate care. Our study demonstrates that evaluating biases in the initial stages of machine learning can provide insights into inequalities in current clinical practice, reveal pathophysiological differences between the male and females, and can mitigate the digitisation of inequalities into algorithmic systems. An awareness of the potential biases of these systems is essential in preventing the digital exacerbation of healthcare inequalities.
  11. News Article
    More than 10,000 people are waiting three months or longer following an urgent referral for suspected cancer, internal NHS data seen by HSJ reveals. Patients with suspected cancer are not supposed to wait more than two months from a referral. However, information shared with HSJ shows that of the 313,000 people on the national cancer waiting list, just over 10,000 had waited 104 days or more. Information about three-month cancer waits is not made public on a regular basis. NHS England publishes data for the total backlog of patients waiting over 62 days, but does not make public the regional or trust-level results, or reveal how many patients are waiting three months or more. One senior figure in cancer policy told HSJ the backlog position was “awful” and “a reflection of a worsening trajectory overwhelming diagnostic capacity in particular”. Breast, skin and lower gastro-intestinal cancers saw the biggest increases in long waiters. Read full story (paywalled) Source: HSJ, 5 July 2022
  12. News Article
    NHS Blood and Transplant (NHSBT) which supplies blood to hospitals is reporting severe supply shortages for the first time since 2018, HSJ has learned. Well-placed senior sources said it is close to issuing a formal “amber alert”, which would mean it could not guarantee blood supplies to hospitals, they said. NHSBT acknowledged to HSJ that it was “expecting a difficult few months”. NHS trusts would have to start cancelling elective operations if they cannot ensure that necessary bloods are available. NHSBT has already written to trusts asking them not to over-order supplies, and to ensure management plans are in place should the situation escalate. Supplies of the common O blood types are thought to be down to less than three days’ worth. If they were to drop to two days, this would trigger an amber alert. Read full story (paywalled) Source: HSJ, 5 July 2022
  13. News Article
    A mother was killed at her hospital appointment by a doctor who botched a routine procedure, a court has heard. Dr Isyaka Mamman, 85, was responsible for a series of critical incidents before the fatal appointment, Manchester Crown Court heard. Mamman, who admitted gross negligence manslaughter, had already been sacked by medical watchdogs for lying about his age but was re-employed by the Royal Oldham Hospital. He is due to be sentenced on Tuesday. Mother-of-three Shahida Parveen, 48, had gone to hospital with her husband for investigations into possible myeloproliferative disorder on 3 September 2018 and a bone marrow biopsy had been advised, Andrew Thomas QC, prosecuting, told the hearing. Normally, bone marrow samples are taken from the hip bone but Mamman, of Cumberland Drive, Royton, Oldham, failed to obtain a sample at the first attempt, he said. Instead, he attempted a rare and "highly dangerous" procedure of getting a sample from Ms Parveen's sternum - despite objections from the patient and her husband, the court heard. Mamman, using the wrong biopsy needle, missed the bone and pierced her pericardium, the sac containing the heart, causing massive internal bleeding. Ms Parveen lost consciousness as soon as the needle was inserted. She died later that day. Read full story Source: BBC News, 4 July 2022
  14. Content Article
    Representatives from Mesh Ireland and Mesh Survivors have this week appeared before the Oireachtas Health Committee, where questions were raised about access to vital diagnostic machines and treament for women who have had vaginal mesh implants put in. Vaginal mesh devices were used to treat issues in women after childbirth, or in their later years, and while it’s not known how many procedures were carried out, it’s believed there were more than 10,000 on the public system alone. Women have experienced painful complications as a result of the procedure and Founder of the Mesh Survivors Ireland Campaign, Melanie Power, who’s a solicitor from Meelick, says many women are unable to work and can’t afford the cost of ongoing treatment. She believes questions need to be answered on why women affected by a post-natal procedure which can cause chronic pain are being means tested for the medical card. Listen to the full interview on Clare FM below.
  15. Content Article
    Over the past year, delays in transferring patients from an ambulance to a hospital have risen exponentially. In April 2022 there were over 41,000 delays of over 60 minutes, up over a staggering 450 per cent in 12 months. This equates to 71,000 hours lost, with a significant risk of harm to patients, even though the proportion being taken to hospital by ambulance has fallen thanks to successful initiatives such as “hear and treat” and “see and treat”. These delays mean that, too often, ambulance crews are not able to respond to 999 calls from critically ill patients. Instead they are being held in “stacks” of hundreds each day – as ambulance control room teams strive to prioritise overstretched resources. The current reality is that crews are often waiting with patients in hospital corridors or outside, hearing urgent calls to which they are unable to respond. In addition to the direct impact on patients, this is incredibly demoralising, even traumatising, for many staff involved. So why is this happening? In an article for the Independent, Daren Mochrie, chair of AACE – the Association of Ambulance Chief Executives, and Saffron Cordrey, interim chief executive at NHS Provider, discusses what is happening in the NHS.
  16. Event
    until
    This free webinar from the Chartered Institute of Ergonomics and Human Factors explores how to apply human factors standards to the design of complex systems. You’ll find out about the benefits, pitfalls and challenges of using standards. You’ll hear about a step-by-step approach to finding solutions in a real-world example of a truly complex system. Register
  17. News Article
    Thalidomide survivors living in Scotland will receive lifelong financial support, the Scottish government has announced. Health Secretary Humza Yousaf said he hoped the commitment to provide grants would reassure those affected. There are 50 known survivors of the banned pregnancy drug living in Scotland, most now in their 60s. They are among thousands born with limb deformities after their mothers took thalidomide while pregnant. The drug was commonly used to treat morning sickness from 1958 to 1961. In 2013 the Scottish government committed £14.2m to help survivors over a 10-year period, with the money going on health and living costs. Ministers have now extended that agreement, with grants to be allocated to survivors on a needs basis, as assessed by the Thalidomide Trust. Mr Yousaf said: "This funding is used to give thalidomide survivors as much assistance as they need to maintain their independence. It has been a vital support in helping people adapt their homes and manage their pain. "I hope this lifelong commitment to continue this support will reassure recipients and help them deal with any challenges they face." Read full story Source: BBC News, 4 July 2022
  18. News Article
    Paramedics have begun looking after patients inside an A&E unit, in an initiative by the health service to stop ambulances queueing outside hospitals and ease the strain on overstretched casualty staff. The scheme has led to patients being handed over much more quickly at a hospital that was one of the worst in England for sick people being stuck, sometimes for many hours, in the back of an ambulance. Queen’s hospital in Romford, in east London, has set up an ambulance receiving centre (ARC) near its main casualty unit in which two London Ambulance Service paramedics are on duty round the clock to help look after patients who would otherwise be trapped outside or in a corridor, waiting to be seen. Patients who end up in the new six-cubicle unit behind the A&E nurses’ station have a better experience while they wait and are more comfortable – and safer – because they can have their relatives with them, eat and drink and use the toilet more easily. Almost 2,000 patients have passed through the ARC since it opened last November, saving nearly 13,000 hours of ambulance crews’ time and enabling them to respond to emergency calls more quickly. However, some A&E doctors regard the scheme as merely “a sticking plaster”, given that queues of ambulances have become common outside many hospitals and that casualty units are treating the lowest percentage of patients within four hours on record. Read full story Source: The Guardian, 3 July 2022
  19. News Article
    An 18-year-old woman suffering a mental health crisis was forced to wait eight-and-a-half days in A&E before getting a bed in a psychiatric hospital – believed to be the longest such wait seen in the NHS. Louise (not her real name) had to be looked after by the police and security guards and sleep in a chair and on a mattress of the floor in the A&E at St Helier hospital in Sutton, south London, because no bed was available in a mental health facility. She became increasingly “dejected, despairing and desperate” as her ordeal continued and, her mental health worsening while she waited, self-harmed by banging her head off a wall. She absconded twice because she did not know when she would finally start inpatient treatment. Louise arrived at St Helier on the evening of Thursday 16 June and did not get a bed in an NHS psychiatric unit until the early hours of Saturday 25 June, more than eight days later. She was diagnosed last year with emotionally unstable personality disorder and ADHD. The mental health charity Mind said it believed it to be the longest wait in A&E ever endured by someone experiencing a mental health crisis, and described it as “unacceptable, disgraceful and dangerous”. It called for urgent action to tackle the inadequacy of NHS mental health provision and bed numbers. “An eight-and-a-half day wait in A&E for a mental health bed is both unacceptable and disgraceful. Mind has never heard of a patient in crisis waiting this long to receive the care they need, and serious questions need to be raised as to how anyone – let alone an 18-year-old – was left to suffer for so long without the care she needs,” said Rheian Davies, the head of Mind’s legal unit. “This is dangerous for staff, who are not trained to give the acute care the patient needs, and dangerous for the patient, who needs that care immediately – not over a week later." Read full story Source: The Guardian, 4 July 2022
  20. News Article
    The government is to cut special sick pay for NHS staff off work with Covid from next week – even as cases soar – The Independent has learnt. The Department of Health and Social Care is set to announce an end to the enhanced pay arrangements provided during the pandemic, meaning that staff who go off sick with either Covid or Long Covid will be subject to normal sick-pay rules. In response to the pandemic, the government announced special arrangements for staff to be paid if they were isolating because of Covid, and to receive a full 12 months’ pay if they were suffering from Long Covid. Arrangements will now revert to the normal NHS sick-pay rules, which give workers six months’ full pay and six months’ half pay. A senior healthcare source said: “They have agreed to end the arrangement for new people from next week, and then have an implementation period where people who are currently off on this sort of scheme revert back to normal sick-pay entitlement from September.” The Royal College of Nursing’s director for England, Patricia Marquis, speaking about the cut in sick pay, said: “This decision is hugely disappointing, given that Covid-19 clearly hasn’t gone away, and nursing staff continue to be disproportionately affected by the virus as they face a higher risk of exposure." Read full story Source: The Independent, 2 July 2022
  21. News Article
    Elective activity levels are still significantly below those achieved before the pandemic, despite the high profile and government-led drive to recover services. HSJ has seen internal data which suggests raw elective activity levels from the start of April to mid-June have averaged around 88% of that recorded in the same period during 2019-20. This is despite the NHS aiming to deliver activity levels of at least 110% above the pre-covid benchmark in 2022-23, in its attempt to make inroads into record elective care waiting lists. According to senior and well-placed sources, the continued low activity levels have sparked discussions within NHSE about easing or resetting the expectations for the year. It had been hoped that increased activity from May onwards would start to drive down the waiting list – or at least slow its growth. However, the data obtained by HSJ suggests activity levels continue to disappoint. Sources pointed to repeated covid waves and related pressures through the spring, saying this has hampered efforts to ramp up activity. Read full story (paywalled) Source: HSJ, 4 July 2022
  22. Content Article
    The Framework for Involving Patients in Patient Safety (PSP) identifies the requirement for individual organisations to develop local approaches to recruiting, working with and supporting Patient Safety Partners based on the principles provided. As integrated care systems (ICSs) are established opportunities for recruiting PSPs at ICS level to work across the system are being locally considered at system level. A focus group was held in May 2022 with Patient Safety Specialists from both provider and commissioning organisations to discuss the benefits and risks of recruiting PSPs at both provider and system level. This presentation is intended to support organisations when determining the most appropriate approach for their needs. 
  23. Content Article
    There was a national roll out of ‘COVID Virtual Wards’ (CVW) during England's second COVID-19 wave (Autumn 2020 – Spring 2021). These services used remote pulse oximetry monitoring for COVID-19 patients following discharge from hospital. A key aim was to enable rapid detection of patient deterioration. It was anticipated that the services would support early discharge, reducing pressure on beds. This study from Georghiou et al. evaluated the impact of the CVW services on hospital activity. The study found no evidence of early discharges or changes in readmissions associated with the roll out of COVID Virtual Wards across England.
  24. Content Article
    The Breastfeeding Friend, a digital tool from Start for Life, has lots of useful information and advice on breastfeeding. And because it's a digital tool, it's available whenever you need it 24 / 7. All the information provided is NHS-approved and based on questions asked by thousands of new mums. Whether you're experiencing breastfeeding difficulties, you've got sore nipples, or you want to know about vitamins and what you should include in your diet – if it's a breastfeeding related question, the Breastfeeding Friend is ready to help you.
  25. Content Article
    ICS Futures is a roundtable series held by the Public Policy Projects ICS Network and chaired by Matthew Swindells, Chair of the North West London Acute Collaborative and former Deputy CEO of NHS England. The Network is made up of senior leaders from across the health and care sectors. The Network convened for three Chatham House roundtables between 16 May and 17 June 2022. The objective of discussions was to highlight challenges and opportunities in integrated care based on real-world examples, to scale best practice and provide ongoing practical advice for system leaders and care providers. Thoughts were also given on key legislative developments, with some national policy recommendations highlighted. This document summarises the key findings and recommendations from each meeting. It is not an exhaustive description of health and care system leaders’ views but rather provides a snapshot into the thoughts and concerns of a specific cohort of senior stakeholders
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