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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    The NHS App will soon be updated with features to help offer people in England more personalised care. It is part of the government's plan for a digital revolution to speed up care and improve access while saving the health service time and money. By March 2023, more users will receive messages from their GP and be able to see their medical records and manage hospital elective-care appointments. By March 2024, the app should offer face-to-face video consultations. The government's ambition is for at least 75% of adults to be using it by March 2024. Currently, less than half - about 28 million - have it on their phone or tablet. The government also wants 90% of NHS trusts to have electronic patient records in place or be processing them by December 2023 and for all social-care providers to adopt a digital social-care record. And patients across the country should be able to complete their hospital pre-assessment checks from home by September 2024. Read full story Source: BBC News, 29 June 2022
  2. Content Article
    Pharmacists and pharmacy technicians across different settings work hard to provide person-centred, safe and effective care to patients. But, in reality sometimes things go wrong. The way that professionals respond to these situations is key to supporting the people affected and improving patient safety for the future. This guidance from the General Pharmaceutical Council aims to provide you with guidance on how to implement the Duty of Candour.
  3. News Article
    When you think of cancer, a glamorous mum in her mid-30s is not the first image that springs to mind. But You, Me and the Big C podcaster Dame Deborah James was just 35 when she found out she had bowel cancer. Blood and stool tests had come back normal and her GP had laughed "not once, but three times over the course of six months" at the idea she could possibly have a tumour in her bowels. The diagnosis came only when she paid to have her colon examined privately. Her experience has raised questions about how good we are at spotting and treating cancer in the under-40s. Simply - are we failing young people with cancer? Overall, around 4.3% of cancers diagnosed in the UK are in the under-40s, while those over 75 make up more than a third of all cancer cases, which poses a challenge for us and the doctors who treat us. When we are young, we're less likely to attribute any ill health to cancer. Changes to our bowel movements could just be stress, blood in the toilet after we poo could be inflammatory bowel disease or haemorrhoids. Because, for most people, cancer is something that happens to our parents or grandparents. Your doctor should be alert to major warning signs of cancer, but there is a medical saying: "When you hear hooves, think horses, not zebras". It's a call to look for the most common or likely explanation, and the younger you are, the less likely cancer is to be behind your symptoms. This helps channel the health service's limited resources to those most likely to need them. But that means some younger people aren't being seen quickly enough, although the problem can affect older people too. Bowel Cancer UK's Never Too Young report in 2020 found that four in 10 people surveyed had to visit their GP three or more times before being referred for further tests to see if they had cancer. "I don't think GPs are a problem," says Genevieve Edwards, chief executive of Bowel Cancer UK. "It [bowel cancer] is rare in younger people... It will usually be something else." The question is - what if you are the zebra, that relatively rare case who does have cancer at a young age?" Read full story Source: BBC News, 14 May 2022
  4. News Article
    Hospitals are bringing back requirements for masks on wards just weeks after rules were relaxed as Covid rates spike, The Independent can reveal. Experts have warned of a surge in cases, believed to be the fifth wave, with one in 40 people in the UK testing positive for the virus. Meanwhile, latest NHS data shows more than 8,000 Covid-positive patients on wards following a warning of a “deleterious” impact on hospital waiting times. In response, three major hospital trusts have told staff they must wear masks, with warnings more must follow if the NHS is to handle another wave of Covid. Dr Tim Cooksley, president of the Society for Acute Medicine told The Independent: “Over the past 2 years Covid has highlighted and exacerbated what was an already growing crisis. “High staff absence levels, burn-out and low morale have dominated staff landscapes during this time and continue to do so. Future waves and potentially large numbers of upcoming flu cases will only serve to deepen these problems making the hopes of patients, clinicians and politicians alike of elective recovery seem somewhat fanciful." Read full story Source: The Independent, 29 June 2022
  5. News Article
    Rapidly falling continuity of care levels pose an “existential threat” to patient safety, Britain’s top family doctor will warn today as research reveals only half of Britons regularly see the same GP. Prof Martin Marshall, chair of the Royal College of GPs (RCGP), will say trusted relationships between family doctors and patients are the most “powerful intervention” for delivering effective, high-quality care as they boost patient satisfaction and health outcomes, and reduce use of hospital services. But in a keynote speech to the college’s annual conference, Marshall will warn that continuity of care is becoming almost impossible to deliver on the NHS amid soaring demand and shrinking numbers of GPs, in what he will describe as the “most worrying crisis in decades”. There are mounting concerns over the ability of the NHS to tackle record waiting lists, with 6.5m patients awaiting care in England alone. Earlier this month Sajid Javid, the health secretary, admitted the current model of GP care “is not working” but insisted there would be no more money for the health service. At the RCGP conference in London, Marshall will tell delegates that because of rising workloads and fewer staff, GPs no longer have the time to properly assess patients, with 65% warning safety is being compromised due to appointments being too short, according to a recent survey commissioned by the college. Only 39% of respondents said they were able to deliver the continuity of care their patients need – down from 60% two years ago. Read full story Source: The Guardian, 29 June 2022
  6. News Article
    The outgoing chief investigator of the national safety watchdog has described his frustration with the organisation’s ‘ambivalent’ relationship with NHS England. Keith Conradi, who is due to retire from the Health Safety Investigation Branch in July, said he did not think he had “ever really spoken to any of the hierarchy in NHS England”. He added “their priorities are elsewhere”. In an interview with health commentator Roy Lilley for the Institute for Health and Social Care Management, Mr Conradi also described HSIB’s relationship with NHSE as “ambivalent”. “It wobbled along that sort of line and got worse as time has gone on,” he said. “At the very start I had a chat with the permanent secretary of the Department of Health and said we would be better off in the department than NHS England. He disagreed and felt that we’d be too close to [then health secretary] Jeremy Hunt, and particularly at that time that would have a negative effect.” Mr Conradi was also critical of the decision to ask HSIB to take on investigations into maternity care early in its life. He said he was “shocked” that it happened so quickly “when we hadn’t really got going”. He continued: “We hadn’t developed a method of doing normal national investigations and suddenly we were being asked to do maternity ones. There was a huge amount of pressure to do this.” Read full story (paywalled) Source: HSJ, 28 June 2022
  7. Content Article
    Dr Harsha Master, Dr Ashish Chaudhry, Dr Nicholas Gall, Dr Louise Newson, Dr Sarah Glynne, and Dr Paul Glynne present their experiences of diagnosing, managing, and referring patients with long COVID and associated conditions. Read this article to learn more about: the definition, prevalence, and symptoms of long COVID exclusion of alternative diagnoses, and identification of red-flag symptoms the authors’ experiences of managing long COVID and its complications.
  8. Content Article
    In this study, Ibrahim et al. evaluated the evidence upon which standards for hospital accreditation by The Joint Commission on Accreditation of Healthcare Organizations (the Joint Commission) are based. They found that in general, recent actionable standards issued by The Joint Commission are seldom supported by high quality data referenced within the issuing documents. The authors suggest that the Joint Commission might consider being more transparent about the quality of evidence and underlying rationale supporting each of its recommendations, including clarifying when and why in certain instances it determines that lower level evidence is sufficient.
  9. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on risk and behaviour to improve patient safety. Key learning objectives: evaluating risk using mapping techniques safety interventions behaviour assessing safety culture The course is facilitated by Perbinder Grewal, a General & Vascular Surgeon, Human Factors & Patient Safety Trainer, and Emotional Intelligence Practitioner; leads on medical education both locally and nationally; Member of the Faculty of Surgical Trainers at the Royal College of Surgeons of Edinburgh; formerly lead for e-learning for healthcare for the Royal College of Surgeons of England; experienced trainer and coach who uses new insights to develop patient safety, staff engagement and psychological safety; has Postgraduate Certificates in Leadership and Coaching. Register
  10. News Article
    The UK response to the removal of the constitutional right to abortion in the US has been one of anger, sadness, and disbelief. The US Supreme Court has voted to overturn the 1973 case of Roe vs Wade, so in effect revoking the constitutional right to abortion that American women have had since the landmark decision. It means the 50 individual US states will be able to set their own abortion laws. Half are expected to ban abortions, some already have, and already clinics across the US have been closing down. The ruling has been widely condemned by the UK’s healthcare organisations, including the British Medical Association and the Royal College of Obstetricians and Gynaecologists. The BMA called it "deeply worrying for the future of women’s reproductive health". Dr Zoe Greaves, chair of the BMA’s medical ethics committee said: "Banning or severely restricting abortion prevents only the safe termination of pregnancy, it doesn’t prevent abortions. If women are denied necessary and appropriate care, they will be forced to travel out of their home state to access services, something which is also being suggested will be made illegal. It could also drive abortion services underground and lead to an increase in self-administered abortions, placing the most vulnerable of women at greatest risk of harm. Restricting abortion will harm ‘rural, minority and poor patients’ the most, according to leading health organisations in the US." Dr Helen Munro, vice-chair of the Faculty of Sexual and Reproductive Healthcare (FSRH) said: "Criminalising abortion and hampering access to care only serves to increase the number of unsafe abortions, putting women’s lives at risk. "All women should be able to receive prompt access to abortion services, which should include good pregnancy decision-making support and access to post-abortion contraception by trained healthcare professionals if they choose." Read full story Source: Medscape, 27 June 2022
  11. News Article
    Reproductive health doctors are reacting to the Supreme Court's decision to overturn Roe vs Wade, the 1973 case that allowed people to seek abortions with limited government intervention. On Friday, Justice Samuel Alito delivered his opinion on the case Dobbs vs Jackson Women's Health, saying he favoured the state of Mississippi in the case. Now, Roe vs Wade, which allowed abortion until about 24 weeks of pregnancy, is overruled, and individual states have the power to decide their residents' abortion rights. OBGYNs who provide abortion care and family-planning services told Insider they worry for their patients' health and safety, and the future of all reproductive healthcare including miscarriages, fertility treatments, and birth control. "This decision made by the SCOTUS is one that completely obliterates freedom from reproductive justice and women's health directly," Dr. Jessica Shepherd, a Texas-based gynecologist and Chief Medical Officer at Verywell Health, told Insider. Dr. Stephanie Ros, a Florida-based OBGYN, says she fears most for working-class abortion seekers. "I'm not worried about my wealthy patients – they will have the means to go 'visit an aunt' in Europe or elsewhere, and access abortion care if they so desire. I'm terrified for my middle class and poor patients, who don't have the means to pick up and travel on a moment's notice, and who often don't have access to medical care to even discover they're pregnant until later than their wealthy counterparts." Read full story Source: Insider, 24 June 2022
  12. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on non-technical skills to improve patient safety. Key learning objectives: task analysis cognitive overload reliability non-technical skills examples The course is facilitated by Perbinder Grewal, a General & Vascular Surgeon, Human Factors & Patient Safety Trainer, and Emotional Intelligence Practitioner; leads on medical education both locally and nationally; Member of the Faculty of Surgical Trainers at the Royal College of Surgeons of Edinburgh; formerly lead for e-learning for healthcare for the Royal College of Surgeons of England; experienced trainer and coach who uses new insights to develop patient safety, staff engagement and psychological safety; has Postgraduate Certificates in Leadership and Coaching. Register
  13. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus 2021. Key learning objectives: Understand the new patient safety landscape Understand the need for proportionality of investigation Learn how to use a range of techniques for conducting PSIIs Understand how to write an impactful improvement plan Consider how your current approach to patient safety investigations compares to the agreed national standards Understand typical pitfalls and traps associated with this wider workstream and tips for avoiding them. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. They have also authored articles on significant event analysis and clinical audit/quality improvement, all techniques seen as increasingly relevant to improving patient safety. Register
  14. Content Article
    This annual publication presents statistics of deaths reported to Coroners in England and Wales in 2021. Information is provided on the number of deaths reported to coroners, post-mortem examinations and inquests held, and conclusions recorded at inquests.
  15. Content Article
    From 28 June 2022, courts and tribunals will have new powers to allow reporters and other members of the public to observe hearings remotely. The purpose of this practice guidance is to help judicial office holders understand and apply the new law.
  16. Content Article
    Extravasation injuries occur when some intravenous drugs leak outside the vein into the surrounding tissue causing trauma. This leaflet describes the risks posed by extravasation to patients, the extent of the problem in the NHS and what is currently being done to reduce the risk of avoidable harm. The leaflet sets out the action to prevent, recognise, treat and report extravasation which is urgently needed. It emphasises the importance of all suspected extravasation injuries being reported and investigated, with reviews undertaken to learn and take action to prevent harm to future patients.
  17. News Article
    Diminishing rates of measles, mumps, and rubella (MMR) jabs have prompted a Royal College warning over the risks to pregnant women, as the NHS raises concerns over London “lagging” behind the national uptake. The Royal College of Paediatrics and Child Health’s immunisations lead, Dr Helen Bradford, said the falling uptake of the MMR vaccine could present a serious risk to pregnant women and their unborn children. The warning comes as London health authorities are planning a major summer drive to improve uptake in the capital, The Independent has learned. Documents seen by The Independent setting out NHS plans for a summer MMR campaign put the focus on social media, including approaching “influencers” to spread messages. The plans also rely on free publicity, with proposals to approach broadcast media. Risks to increasing uptake, according to the document, included anti-vaxx sentiment towards MMR, apathy towards the vaccine, controversy meaning influencers won’t work with the NHS, and a lack of internal data. Read full story Source: The Independent, 27 June 2022
  18. News Article
    Suffering is “the new norm” in the NHS and people can expect to spend their last few years in pain, the outgoing chairman of the British Medical Association said. Chaand Nagpaul, who steps down this week, said the NHS was in a “perilous state”. He also wants people to have sympathy for the “plight” of junior doctors, who have said they will prepare for a ballot on strikes over pay. There are 6.5 million people on NHS waiting lists, many of whom have been waiting a year or more. Nagpaul, who has been a GP for 33 years, said: “I have not come across this scale of suffering, of unmet need. And what we’re going to be seeing is people spending the last years of their lives, literally in pain, unable . . . to have a hip operation. That will be the final years of their lives.” He said there was a “whole, larger population of patients just literally not featuring in the statistics” waiting for outpatient treatment, mental health care and diabetes checks. Read full story (paywalled) Source: The Times, 27 June 2022
  19. News Article
    Doctors have thrown down the gauntlet to the government by calling for a pay rise of up to 30% over the next five years, in a move that increases the chances of strike action. Delegates at the British Medical Association’s (BMA) annual conference voted to press ministers to agree to the increase to make up for real-terms cuts to their salaries over the last 14 years. Frontline doctors said years of pay freezes and annual salary uplifts of 1% had caused the real value of their take-home pay to fall by almost a third since 2008. They now want “full pay restoration” to return the value of their pay to 2008 levels, and have instructed the BMA to pursue that goal with a government that has made clear it will not hand public sector workers sizeable salary increases in case it fuels already rampant inflation. The motion noted “with horror that all doctors’ pay has fallen against RPI [the retail prices index] since 2008 to the tune of up to 30%”. It said the BMA’s leadership should “achieve pay restoration to 2008 for its members within the next five years” and report back annually on progress. Proposing the motion, Dr Emma Runswick, a member of the BMA’s ruling council, said: “We should not wait for things to get worse. All of us deserve comfort and pleasure in our lives. Pay restoration is the right, just and moral thing to do. But it is a significant demand and it won’t be easy to win. Every part of the BMA needs to plan for how to achieve this.” Read full story Source: The Guardian, 27 June 2022
  20. News Article
    Former prime minister Sir John Major has described the contaminated blood scandal as "incredibly bad luck", drawing gasps from families watching him give evidence under oath to the public inquiry into the disaster. Up to 30,000 people contracted HIV and hepatitis C in the 1970s and 80s after being given blood treatments or transfusions on the NHS. Thousands have since died. Sir John later apologised for his choice of language. He said: "I obviously caused offence inadvertently this morning when I referred to the fact that it was awful that people had been fed infected blood and I referred to it as sheer bad luck. "I can only say to people it wasn't intended to be offensive. I was seeking to express the fact that I was concerned about what happened. "It was intended simply to say that it was a random matter and I perhaps expressed it injudiciously." The UK-wide inquiry was launched after years of campaigning by victims, who claim the risks were never explained and that the scandal was covered up. Campaigners say those infected decades ago are now dying at the rate of one every four days as a result. Read full story Source: BBC News, 27 June 2022
  21. News Article
    A possible link between blood clots and ongoing symptoms of Covid is under scrutiny by researchers in the UK. While Covid can cause a period of acute illness, it can also lead to longer-term problems. Research has suggested fewer than a third of patients who have ongoing Covid symptoms after being hospitalised with the disease feel fully recovered a year later. Now researchers are due to begin a number of trials to explore whether blood thinners may help those who have had the disease. Prof Ami Banerjee, of University College London, who is leading a study called Stimulate-ICP, said it was known that a Covid infection increases the risk of blood clots, and that people who have had the disease have a greater risk of related conditions including stroke, heart attacks and deep vein thrombosis. In addition, Banerjee said research from scientists in South Africa had suggested that people with long Covid have microclots in their blood, while studies in the UK suggested almost a third of long Covid patients have clotting abnormalities. But he said it was not clear if the findings were generalisable, and while there had been calls on social media for anticoagulants to be made available on the basis of such findings, further research was needed, not least as blood thinners can lead to an increased risk of bleeds. Read full story Source: The Guardian, 27 June 2022
  22. Content Article
    This white paper from the Institute for Healthcare Improvement (IHI) describes a framework to guide health care organisations in their efforts to provide safe, equitable, person-centred telemedicine. The framework includes six elements to consider: access, privacy, diagnostic accuracy, communication, psychological and emotional safety, and human factors and system design.
  23. Content Article
    Reducing stress is an organisational imperative since workplace pressures continue to be one of the main causes of short and long-term absence. According to research undertaken by CIPD based on responses from 804 organisations, 79% of respondents report some stress-related absence in their organisation over the last year. Healthcare settings have an even higher rate of absence due to stress, yet there is reason to be optimistic that this could start to change when a new policy from NHS England is implemented, which recommends the use of After Action Review (AAR). In this blog, Judy Walker explains how AARs can play a key role in reducing stress for those who have been involved in clinical incidents.  
  24. News Article
    The effects of the Supreme Court's proposed overrule of Roe vs Wade will touch health systems nationwide — leading some clinicians to urge industry leaders to start preparing for potential fallout prior to the decision. "Health systems that view abortion exclusively as a political or partisan issue, perhaps one they'd like to avoid, will soon bear witness to the reality that abortion care, or lack thereof, is a healthcare and health equity issue," Lisa Harris, MD, PhD, wrote in a 11 May for The New England Journal of Medicine. "Avoiding the issue will not be possible, short of abandoning care and equity missions altogether. Thoughtful preparation is needed now." Four leaders at three systems share there insights. Read full story Source: Becker's Hospital Review, 23 June 2022
  25. Event
    This on-demand conference focuses on supporting staff who have been involved in patient safety incidents, or are the subject of complaints or claims. Involvement in an incident, complaint or claim can have severe consequences on staff who may experience a range of reactions including stress, depression, shame and guilt. This conference will enable you to: Network with colleagues who are working to support staff following incidents, complaints or claims. Understand national developments including the requirements in the 2020 Patient Safety Incident Response Framework. Reflect on how we can better support staff experiencing these issues through Covid-19. Deliver a just culture that supports consistent, constructive and fair evaluation of the actions of staff involved in patient safety incidents. Reflect on a healthcare’s professionals personal experience of being the subject of an incident investigation. Improve immediate support and debriefing when an incident occurs. Develop your skills in providing the staff member involved in a patient safety incident specific individual support or intervention to work safely. Understand how you can improve processes for ensuring candour and supporting staff. Identify key strategies for interviewing staff and taking statements and preparing staff for Coroner’s Inquests. Ensure you are up to date with the latest developments in psychological support for staff including building resilience. Self assess and reflect on your own practice. Gain CPD accreditation points contributing to professional development and revalidation evidence. For more information https://www.healthcareconferencesuk.co.uk/on-demand-training/patient-safety-incident-complaint-claim or email kerry@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #SupportingClinicians
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