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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
    This virtual masterclass will guide you in how to use Human Factors in your workplace. All medical and non-medical staff should attend. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. It can be used to assess why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. 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 For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/human-factors-workplace or email nicki@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code.
  2. Content Article
    Derek Richford shares Harry's Story from last year's HSJ Patient Safety Congress. Derek is grandfather of Harry Richford who died seven days after an emergency delivery at  East Kent Hospitals Trust. Derek is joined by Donna Ockenden, Chair of the Independent review of maternity services at Shrewsbury & Telford Hospital, and Sarah-Jane Marsh, Chair of NHS England's Maternity transformation programme, in the 'Actioning recommendations from the Ockenden report' session at the Congress.
  3. Content Article
    We’re looking for patients to help raise awareness of the damaging impact that surgical infections can have on people, and guide improvements. Have you ever been in surgery and contracted an infection? Do you want to share your experience anonymously and help create change? Take part in this survey: Experiences of Surgical Infections
  4. News Article
    NHS patients in England who have been waiting more than two years for surgery are being offered hospital treatment in alternative parts of the country. More than 6,000 long-term waiting-list patients are being offered travel and accommodation costs where appropriate to help the NHS through the backlog. Health officials want to ensure nobody is waiting more than two years by the end of July. Three patients waiting for surgery in Derby have already received treatment in the Northumbria health region, with another two patients booked in, NHS England said. And in south-west London, 17 orthopaedic patients from the South West of England are being treated, with another 11 patients set to follow in the coming weeks. Health and Social Care Secretary Sajid Javid said the number of two-year waits had already reduced by two-thirds since January. "Innovations like this are helping to tackle waiting lists and speed up access to treatment, backed by record investment," he said. But British Medical Association leader Dr Chaand Nagpaul is warning that attempts to address what he called a "once in a generation backlog of unimaginable proportions" would be undermined by a lack of staff and beds. Read full story Source: BBC News, 27 June 2022
  5. News Article
    New plans to strengthen the regulation of medical devices to improve patient safety and encourage innovation have been published. Following the UK’s exit from the European Union (EU), the Medicines and Healthcare products Regulatory Agency (MHRA) has a unique opportunity to improve how medical devices and in vitro diagnostic medical devices (IVDs) are regulated in the UK. The package of reforms will apply to medical devices such as hearing aids, x-ray machines and insulin pumps; new technologies such as smartphone apps and Artificial Intelligence (AI); as well as certain cosmetic products like dermal fillers. The new measures include: Strengthening the MHRA’s powers to act to keep patients safe. Giving the public and patients greater assurance on both the performance and safety of the highest-risk medical devices, such as those which need to be implanted. Increasing the scope and extent of regulation to respond to public need. Enhancing systems that are already in place to better protect users of medical devices and certain cosmetic products, and providing greater assurance of their performance and safety. Addressing health disparities and mitigating identified inequities throughout medical devices development and use. Mitigating against inequities in medical devices, ensuring they function as intended for diverse populations. The government has launched a review into the potential equity issues in the design and use of medical devices to tackle health inequalities and will update in due course. Making the UK a focus for innovation, and the best place to develop and introduce innovative medical devices. Ensuring the new regulatory framework encourages responsible innovation so that patients in the UK are better able to access the most advanced medical devices to meet their needs. Setting world-leading standards and building the new UKCA mark. Transforming a new stamp of certification, replacing the CE mark, into a trusted brand that signifies global safety, health and environment protection standards have been met for medical device products. This will in turn boost the MHRA’s global reputation and growing partnerships with other regulators. Health and Social Care Secretary Sajid Javid said: "Now we have left the EU, these new changes will allow innovation to thrive and ensure UK patients are among the first to benefit from technological breakthroughs." "We are now able to introduce some of the most robust safety measures in the world for medical devices to ensure patients are protected." Read press release Source: Gov.UK, 26 June 2022
  6. News Article
    Surgery waiting lists will triple by 2030, triggering a “population health crisis”, unless there is a huge increase in NHS capacity, according to new research. Experts from Birmingham University have said efforts to reduce hospital backlogs are not enough and that it is “impossible” for the existing frontline workers to tackle increasing waiting lists. The most in-depth analysis of the challenge facing hospital waiting lists in England has revealed 4.3 million people need invasive surgery or procedures such as endoscopy, the largest number since 2007. Of these, an estimated 3.3 million are on a “hidden waiting list”, likely to need treatment but yet to be identified by the NHS due to the impact of the pandemic. More than 2.3 million people, 53% of the waiting list, are of working age, meaning their delayed diagnoses and treatments could have an impact on the economy. Without a substantial increase in NHS capacity, the team behind the work say the total figure for those waiting for surgery in England could rise to 14.6 million by 2030. Read full story (paywalled) Source: The Times, 26 June 2022
  7. News Article
    Patients will not be able to directly contact Scotland’s new Patient Safety Commissioner under the role’s proposed remit, according to the Sunday Post. Officials drawing up the job description for the position are proposing patients with concerns and complaints should go through their local health boards instead of dealing directly with the commissioner. Last week, Henrietta Hughes was named as the government’s preferred candidate for the role of Patient Safety Commissioner in England. In that role, Hughes will be able to be directly contacted by the public. Despite being the first UK country to announce the intention to appoint a commissioner two years ago the role in Scotland is not yet filled. The decision not to allow patients to directly contact the commissioner in Scotland has been criticised by Baroness Julia Cumberlege, author of the report, First Do No Harm. She said: “Of course, patients must be able to communicate directly with the commissioner and their office. In our review we said the healthcare system is not good enough at spotting trends in practice and outcomes that give rise to safety concerns. Listening to patients is pivotal to that. “This is why one of our principal recommendations was the appointment of an independent Patient Safety Commissioner, a person of standing who sits outside the healthcare system, accountable to parliament through the Health and Social Care Select Committee." Read full story Source: The Sunday Post, 26 June 2022
  8. News Article
    Senior doctors have drawn up a major dossier refuting Sajid Javid’s claim that the pressures on the NHS were created by the Covid pandemic, amid continued warnings over patient safety, scarce beds and staff morale. The health secretary has repeatedly suggested that the problems around record waiting lists and ambulance waiting times have been prompted by the pandemic. Last week in parliament, he accused shadow health secretary Wes Streeting of having his “head under a rock for two years” for not seeing that the pressures stemmed from Covid. However, in a major review of evidence shared with the Observer, doctors pointed to issues around funding, bed capacity, staffing and recruitment that pre-dated the arrival of Covid. The dossier, drawn up by the British Medical Association as it gathers for its annual conference this week, finds that the UK’s health services were ill-prepared for the pandemic as a result of “historical underfunding and under-resourcing in the decade preceding the virus”. Denise Langhor, an emergency medicine consultant in the north-west of England, said that the pandemic had “laid bare” the health service’s problems, but did not create them. “Those problems and those holes already existed,” she said. “It is entirely disingenuous of this government to claim the waiting lists and the difficulties people are experiencing with NHS care at the moment are due to Covid. They have been building for a decade. “Every day, I have patients that I wish I could have treated sooner. It’s an awful thing as a doctor to be trying to look after patients on a corridor, and knowing they are not getting the standard of care that you want to give them. “Frequently it feels like we’re operating by choosing the least worst option rather than the best option.” Read full story Source: The Guardian, 26 June 2022
  9. News Article
    The UK needs to do more to use diagnostic testing in the fight against antimicrobial resistance (AMR), the chair of a government-commissioned review on AMR told MPs. Lord O’Neill, an economist and former treasury minister, warned in the review’s final report in 2016 that a continued rise in AMR would lead to 10 million people dying each year by 2050 and made ten recommendations, including the need for rapid diagnostics to reduce unnecessary use of antimicrobials. Speaking to a Commons Science and Technology Committee evidence session on 22 June 2022, Lord O’Neill said that while he was pleased with progress on some of the recommendations published in his review in 2016, especially in the reduction of antimicrobials in agriculture, progress on diagnostics was “woeful”. He said it was “alarming to me how we are not embedding state-of-the-art diagnostic technology right in the middle of our health systems”, adding that it could “really make a huge difference about whether an antibiotic is needed or not, and the right kind of antibiotic”. “Our most aggressive recommendation was that we should ban the use of subjective prescriptions in secondary settings, at least in Western countries, until they’ve gone through a state-of-the-art diagnostics,” he continued. “And nobody’s done it; they claim it’s a vicious circle, the technology isn’t there, but we have to give incentives in order to get this embedded because that would make a permanent difference.” Read full story Source: The Pharmaceutical Journal, 24 June 2022
  10. Content Article
    Human error plays a vital role in diagnostic errors in the emergency department. A thorough analysis of these human errors, using information-rich reports of serious adverse events (SAEs), could help to better study and understand the causes of these errors and formulate more specific recommendations. Baartmans et al. studied 23 SAE reports of diagnostic events in emergency departments of Dutch general hospitals and identified human errors. They found that the combination of different instruments and information-rich SAE reports allowed for a deeper understanding of the mechanisms underlying diagnostic error. Results indicated that errors occurred most often during the assessment and the testing phase of the diagnostic process. Most often, the errors could be classified as mistakes and violations, both intended actions. These types of errors are in need of different recommendations for improvement, as mistakes are often knowledge based, whereas violations often happen because of work and time pressure. These analyses provided valuable insights for more overarching recommendations to improve diagnostic safety and would be recommended to use in future research and analysis of (serious) adverse events.
  11. Content Article
    Adverse events in surgery are a relevant cause of costs, disability, or death, and their incidence is a key quality indicator that plays an important role in the future of health care. In neurosurgery, little is known about the frequency of adverse events and the contribution of human error. The aim of this study from Meyer et al. was to determine the incidence, nature and severity of adverse events in neurosurgery, and to investigate the contribution of human error. They found that adverse events occur frequently in neurosurgery. These data can serve as benchmarks when discussing quality-based accreditation and reimbursement in upcoming health care reforms. The high frequency of human performance deficiencies contributing to adverse events shows that there is potential to further eliminate avoidable patient harm.
  12. Content Article
    Much progress in the world depends on the spread of ideas, says Steven Shorrock in his new blog. There is no shortage of good ideas, and no shortage of bad ones, but ‘good’ and ‘bad’ are relative to our positions, and success and failure are not dependent on either. The success of an idea depends on a multitude of factors, such as the the multiverse of contexts in which it is introduced, the dominant paradigm, the nature of the related problem situation or opportunity, the quality of the idea itself, the communication of the idea, possible unwanted consequences, and the characteristics of the proponents and detractors.
  13. News Article
    Covid vaccines cut the global death toll by 20 million in the first year after they were available, according to the first major analysis. The study, which modelled the spread of the disease in 185 countries and territories between December 2020 and December 2021, found that without Covid vaccines 31.4 million people would have died, and that 19.8 million of these deaths were avoided. The study is the first attempt to quantify the number of deaths prevented directly and indirectly as a result of Covid-19 vaccinations. “We knew it was going to be a large number, but I did not think it would be as high as 20 million deaths during just the first year,” said Oliver Watson, of Imperial College London, who is a co-first author on the study carried out by scientists at the university. Many more deaths could have been prevented if access to vaccines had been more equal worldwide. Nearly 600,000 additional deaths – one in five of the Covid deaths in low-income countries – could have been prevented if the World Health Organization’s global goal of vaccinating 40% of each country’s population by the end of 2021 had been met, the research found. “Our findings show that millions of lives have likely been saved by making vaccines available to people everywhere, regardless of their wealth,” said Watson. “However, more could have been done.” Read full story Source: The Guardian, 24 June 2022
  14. Content Article
    The first COVID-19 vaccine outside a clinical trial setting was administered on 8 December 2020. To ensure global vaccine equity, vaccine targets were set by the COVID-19 Vaccines Global Access (COVAX) Facility and WHO. However, due to vaccine shortfalls, these targets were not achieved by the end of 2021. Watson et al. aimed to quantify the global impact of the first year of COVID-19 vaccination programmes. The study found that COVID-19 vaccination has substantially altered the course of the pandemic, saving tens of millions of lives globally. However, inadequate access to vaccines in low-income countries has limited the impact in these settings, reinforcing the need for global vaccine equity and coverage.
  15. News Article
    NHS England has published its new and updated national Freedom to Speak Up policy, which is applicable to primary care, secondary care and integrated care systems. Together with NHS England, the National Guardian’s Office has also published new and updated Freedom to Speak Up guidance and a Freedom to Speak Up reflection and planning tool. Each will help organisations deliver the People Promise for workers, by ensuring they have a voice that counts, and by developing a speaking up culture in which leaders and managers value the voice of their staff as a vital driver of learning and improvement. NHSE is asking all trust boards to be able to evidence by the end of January 2024: An update to their local Freedom to Speak Up policy to reflect the new national policy template. Results of their organisation’s assessment of its Freedom to Speak Up arrangements against the revised guidance. Assurance that it is on track implementing its latest Freedom to Speak Up improvement plan. Dr Jayne Chidgey-Clark said: “The publication of the updated universal Freedom to Speak Up Policy for the sector is an opportunity for organisations to refresh their Freedom to Speak Up arrangements. The new guidance we have developed in collaboration with NHS England will help leaders throughout the sector turn that policy into a healthy and supportive Speak Up, Listen Up, Follow Up culture.” Read more Source: National Guardian Freedom to Speak Up, 23 June 2022
  16. Content Article
    This improvement tool is designed to help NHS organisations identify strengths their leadership team and organisation, and any gaps that need work, in seeking to create an environment where people feel safe to speak up with confidence. It should be used alongside Freedom to speak up: A guide for leaders in the NHS and organisations delivering NHS services, which provides full information about the areas addressed in the statements, as well as recommendations for further reading.
  17. News Article
    The number of patients in English hospitals who have tested positive for Covid has increased 28% in a week, the steepest rise since mid-March The third Covid wave of 2022 has now seen Covid occupation levels rise from 3,835 on 4 June to 6,401 yesterday. The sharpest rise in the number of Covid positive patients came in the North West region, where the total rose by 43% in a week. There are now over 1,000 Covid positive hospital patients in the North West, North East and Yorkshire, Midlands and London regions for the first time since 11 May. Some 38% of Covid hospital patients are being treated primarily for the condition. Read full story (paywalled) Source: HSJ, 24 June 2022
  18. Content Article
    Integrated care systems (ICSs) face a difficult task. The health of the population and the scope of some of the major concerns vary considerably across ICSs. As a result, authorities need to examine all aspects to ensure that ICSs run effectively, writes Phoebe Dunn in this HSJ article.
  19. Content Article
    This guide provides ideas for how an organisation can adhere to the NHS principles for leaders and managers in seeking to create an environment where people feel safe to speak up with confidence. This guide is designed to be used by any senior team, owner or board in any organisation that delivers NHS commissioned services. This includes all aspects of primary care; secondary care; and independent providers.
  20. Content Article
    This policy provides the minimum standard for local freedom to speak up policies across the NHS, so those who work in the NHS know how to speak up and what will happen when they do. All NHS organisations and others providing NHS healthcare services in primary and secondary care in England are required to adopt this policy. This includes a template where organisations can incorporate their own local information into the policy document.
  21. News Article
    A doctor who attempted to cover up the true circumstances of the death in 1995 of a four-year-old patient has been struck off. Consultant paediatric anaesthetist Dr Robert Taylor dishonestly misled police and a public inquiry about his treatment of Adam Strain, who died at the Royal Belfast Hospital for Sick Children, a medical tribunal found. The youngster was admitted for a kidney transplant at the hospital following renal failure but did not survive surgery in November 1995. Six months later an inquest ruled Adam died from cerebral oedema – brain swelling – partly due to the onset of dilutional hyponatraemia, which occurs when there is a shortage of sodium in the bloodstream. Two expert anaesthetists told the coroner that the administration of an excess volume of fluids containing small amounts of sodium caused the hyponatraemia. But Dr Taylor resisted any criticism of his fluid management and refused to accept the condition had been caused by his administration of too much of the wrong type of fluid. In 2004 a UTV documentary When Hospitals Kill raised concerns about the treatment of a number of children, including Adam, and led to the launch of the Hyponatraemia Inquiry. The tribunal found Dr Taylor acted dishonestly on four occasions in his dealings with the the public inquiry, including failing to disclose to the inquiry a number of clinical errors he made and falsely claiming to detectives he spoke to Adam’s mother before surgery. Read full story Source: The Independent, 22 June 2022
  22. News Article
    The NHS is urgently tracking down the parents of 35,000 five-year-old children in London who are not fully vaccinated against polio. Health officials are hoping to contain the spread of the virus after detecting the first outbreak since 1984. They are trying to trace it back to a “single household or street” after identifying polio in a sewage plant serving four million people in northeast London. Experts are concerned polio, which had been eradicated in Britain in the 1980s, could take off again due to relatively low vaccination uptake in London. Latest NHS data shows 101,000 five-year-olds in England — 15% of the total — have not had their booster polio dose, offered when they reach the age of three. One third of these, 34,104 in total, live in London. Jane Clegg, the chief NHS nurse for London said they are “reaching out to parents of children aged under five in London who are not up-to-date with their polio vaccinations to invite them to get protected.” Read full story Source: The Times, 23 June 2022
  23. News Article
    The cost of living crisis is adding to pressures on GPs, the British Medical Association (BMA) in Northern Ireland has warned. The BMA said that is because the number of people asking for prescriptions for medicines that can be bought over the counter is increasing. That includes medicines like painkillers and allergy medication, Dr Alan Stout of the BMA said. Prescriptions are free for everyone in Northern Ireland. The rise in prescription request increases "the cost to the health service as a whole and the pressure on GPs", Dr Stout told Ulster's Good Morning Ulster programme. "We have talked before about the difficulties people have accessing GPs and this is just more demand and difficulties," he said. Dr Stout added: "I absolutely don't hold that against anyone, it is not our position as GPs to deny people medication or deny people prescriptions if they need this medication." Read full story Source: BBC News, 23 June 2022
  24. News Article
    A drive to ‘transform’ access to urgent, emergency and planned care will be added to the goals of the NHS long-term plan, a document leaked to HSJ has revealed The long-term plan for the NHS was originally published in January 2019. Last September, NHS England said it was reviewing the commitments made within the plan, with senior officials warning that many of them could not be met after the damage of the pandemic. HSJ has seen a document prepared for the most recent meeting of the NHS Assembly which sets out NHSE’s approach to the refresh. Strategic developments expected include better joined-up community based and preventive care, transform access to urgent, emergency and planned care, improve care quality and operations, and tackle health inequalities, improve population health and develop a sustainable health service through greater collaboration. Read full story (paywalled) Source: HSJ, 24 June 2022
  25. News Article
    A hospital and one of its managers are facing a criminal investigation into the death of a vulnerable man who absconded by climbing a fence. An inquest concluded failings amounting to neglect contributed to the death of Matthew Caseby in 2020, after he fled from Birmingham's Priory Hospital Woodbourne and was hit by a train. The investigation will be carried out by the Care Quality Commission (CQC). Priory said it would co-operate fully "if enquiries are raised by the CQC". Mr Caseby, 23, climbed over a 2.3m-high (7ft 6in) courtyard fence on 7 September 2020. He was found dead the following day after being hit by a train near Birmingham's University station. The inquest in April heard other patients had previously climbed the fence and, despite concerns by members of staff, no action was taken to improve security in and around the courtyard until another patient absconded two months after Mr Caseby's death. Following the inquest, coroner Louise Hunt said she was concerned the fence and courtyard area may still not be safe and urged health chiefs to consider imposing minimum standards for perimeter fences at mental health units. She also criticised record-keeping and how risk assessments were carried out. Read full story Source: BBC News, 23 June 2022
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