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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Systems and processes in place around patient safety failed in terms of the work of a Belfast-based neurologist, an inquiry has found. Dr Michael Watt was at the centre of Northern Ireland’s largest ever recall of patients, which began in 2018, after concerns were raised about his clinical work. More than 4,000 of his former patients attended recall appointments. Almost a fifth of patients who attended recall appointments were found to have received an “insecure diagnosis”. The final report following the Independent Neurology Inquiry found that problems with Dr Watt’s practice were missed for years and opportunities to intervene were lost. It makes 76 recommendations to the Department of Health, healthcare organisations, General Medical Council and the independent sector. “While one process or system failure may not be critical, the synergistic effect of numerous failures ensured that a problem with an individual doctor’s practice was missed for many years and, as this inquiry finds, opportunities to intervene, particularly in 2006/2007, 2012/2013, and earlier in 2016 were lost,” the inquiry found. Read full story Source: The Independent, 21 June 2022
  2. Content Article
    The Belfast Health Trust failed to intervene quickly enough in the practice of a doctor which led to Northern Ireland's largest ever patient recall, the Independent Neurology Inquiry has found. More than 5,000 former patients of neurologist Michael Watt were invited to have their cases examined for possible misdiagnoses. Among the conditions being treated were stroke, Parkinson's disease and multiple sclerosis (MS). The inquiry found "numerous failures". The Independent Neurology Inquiry concluded that the combined effect of the failures ensured that patterns in the consultant's work were missed for a decade.
  3. News Article
    Ground breaking new data on community services appears to show enormous variation between areas in the number of referrals for a “two-hour urgent response” being recorded. NHS England has published new provisional data on the performance of urgent community response services against a key NHS long-term plan target of reaching at least 70% of patients referred to them within two hours by December 2022. It is the first time performance data has been published for community health services. It also includes the number of referrals made which are reported as “in scope” of the target, and the total number of service contacts. There is huge variation in both referrals and contacts, not accounted for by the size of areas or population need. The publication of the first national performance data for community services was described as “an important moment for community providers” by Siobhan Melia, chair of the Community Network, which is part of NHS Providers and the NHS Confederation. She added it would “raise the profile of community services, and shine a light on the important work taking place in the sector”. Read full story (paywalled) Source: HSJ, 21 June 2022
  4. Event
    This day will explore what clinical governance means for frontline clinicians. Based on experiential learning techniques, drawing on live case studies and shared experiences of the participants, it looks at the challenges that colleagues working in healthcare settings encounter as part of their journey into patient safety and overall clinical governance and what needs to happen to the system safer for the staff and the patients. Working in partnership, this day draws on expertise from the healthcare leaders and front line clinicians from BAPIO. It is grounded in principles of clinical governance which will be brought to life by the diverse experience and skills of the delivery team. The conference is open to anyone working in a health care setting who is involved in leadership role or providing care to patients. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/reinvigorating-clinical-governance 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 #ClinGov
  5. Event
    This conference focuses on patient involvement and partnership for patient safety including implementing the New National Framework for involving patients in patient safety, and developing the role of the Patient Safety Partner (PSP) in your organisation or service. The National Framework for involving patients in patient safety was released by NHS England in June 2021. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/patient-involvement or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub,org. Follow on Twitter @HCUK_Clare #PatientPSP2022
  6. Event
    This one day masterclass will focus on a toolkit to allow organisations to use patient experience and incident to improve patient safety. The Toolkit uses 3 phases: planning, implementation and review. The Francis Report showed that the NHS had stopped listening to the needs of its users. Patient experience is still an underutilised tool in the armoury of a healthcare organisation and commissioners. The toolkit uses the priorities of the Francis Report to improve patient experience and patient safety. These include putting patients first, openness, candour, accountability, complaints handling, culture of caring and compassionate leadership. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/patient-experience-and-learning-from-incidents-to-improve-safety or email aman@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.
  7. Event
    Note: this conference has been rescheduled from the 14 September 2022. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts and will reflect on learning from deaths. There will be a focus on mortality review during the Covid pandemic and how mortality investigation should be managed in these cases. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. The conference will also update delegates on the New National Patient Safety Incident Response Framework including sharing experience from an early adopter site. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-and-learning-from-deaths-in-nhs-trusts or email nicki@hc-uk.org.uk hub members can receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #LFDNHS
  8. 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. It 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 systems to improve patient safety. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/systems-approach-patient-safety-masterclass or click on the title above or email kate@hc-uk.org.uk hub members can receive a 20% discount. Email info@pslhub.org for discount code.
  9. Event
    This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. The course pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a team-based approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-1-day-masterclass or email kate@hc-uk.org.uk. We are pleased to offer hub members a 20% discount. Please email info@pslhub.org for the code.
  10. Event
    This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. The course pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a team-based approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-1-day-masterclass or email kate@hc-uk.org.uk. We are pleased to offer hub members a 20% discount. Please email info@pslhub.org for the code.
  11. Content Article
    Mesh complications are rare and in most cases relatively minor. However, in a small number of cases they can be serious. These include mesh erosion/extrusion (when the mesh pokes through the vaginal wall or cuts through internal tissue), vaginal scarring, fistula formation, painful sex, bladder infection or perforation (piercing), bowel and nerve trauma and pelvic, back and leg pains. Some of these complications may occur years after surgery and can be difficult to treat. Serious complications are rare, given the tens of thousands of women who have had the implants, but can be life-changing for some women. As a result of concerns raised by mesh-affected women, in April 2018 the then Secretary of State for Health and Social Care, Jeremy Hunt MP, announced a review into the use of vaginal mesh. The review was led by Baroness Julia Cumberlege and recommendations made in the report of the Independent Medicines and Medical Devices Safety (IMMDS) “First Do No Harm”. The Government published its response to the IMMDS Review in July 2021.
  12. News Article
    People with disabilities must be helped more by health providers to access information, a report has found. Over 300 people in North Yorkshire were asked about communication from GPs, hospitals, and healthcare providers in a survey by watchdog Healthwatch. The report said there is "some good practice" but many patients are not being contacted in their preferred format. This leads to missed appointments which "costs time and money". Since 2016, the Accessible Information Standard means health and care organisations must legally provide a "consistent approach to identifying, recording, flagging, sharing, and meeting the information and communication support needs of patients, service users, carers and parents with a disability, impairment, or sensory loss," Healthwatch said. But the report said some people receive printed letters which they are unable to read meaning they have to ask for private and confidential information to be relayed. Scarborough respondent Ian said it was "amazing" that in the 21st Century many are still facing such issues. "The [GP booking] system doesn't anticipate that not everyone can use the phone," he said. "The problem is a lot of organisations haven't moved with the times". Read full storyp Source: BBC News, 21 June 2022
  13. News Article
    More than 80% of UK medical certificates recording stillbirths contain errors, research reveals. More than half the inaccurate certificates contained a significant error that could cause medical staff to misinterpret what had happened. The study, published in the International Journal of Epidemiology, also shows that three out of four stillbirths certified as having an "unknown cause of death" could, in fact, be explained. A team from the Universities of Edinburgh and Manchester examined more than 1,120 medical certificates of stillbirths, which were issued at 76 UK obstetric units in 2018. Of the 421 which were resolved, 195 were re-designated as foetal growth restriction (FGR), and 184 as placental insufficiency. Dr Michael Rimmer, clinical research fellow at Edinburgh University’s MRC Centre for Reproductive Health, said: “This study shows some medical certificates of stillbirths contain significant errors. "Reducing these errors and accurately recording contributing factors to a stillbirth is important in shaping research and health policies aimed at reducing the number of stillbirths. Read full story Source: The Herald, 21 June 2022
  14. Content Article
    The Medical Certificate of Stillbirth (MCS) records data about a baby’s death after 24 weeks of gestation but before birth. Major errors that could alter interpretation of the MCS were widespread in two UK-based regional studies. A multicentre evaluation was conducted, examining MCS issued 1 January 2018 to 31 December 2018 in 76 UK obstetric units. A systematic case-note review of stillbirths was conducted by Obstetric and Gynaecology trainees, generating individual ‘ideal MCSs’ and comparing these to the actual MCS issued. Anonymized central data analysis described rates and types of error, agreement and factors associated with major errors. The study demonstrates widespread major errors in MCS completion across the UK. MCS should only be completed following structured case-note review, with particular attention on the fetal growth trajectory. Correct stillbirth cause classification is crucial for families and society; when ‘unexplained’, conditions’ true perinatal mortality contributions are uncounted and preventative strategies cannot be appropriately targeted.
  15. News Article
    Government will pick five or six ‘integration frontrunner’ areas ‘to lead the way in developing and testing radical new approaches’ to speeding up discharge from acute hospitals. Along with NHS England, ministers today wrote to local NHS and council directors asking for bids to take part by 30 June. They said there was “a need to take a more fundamental look at [how the] system currently manages the discharge of patients, their post-acute care, and their access to high-quality social care”. The “discharge integration frontrunner sites” will focus on exploring “new service models, such as the delivery of a more integrated model for intermediate care across existing health and social care”, and “designing and testing new enabling arrangements, which might include new funding models, more integrated workforce models, or the deployment of new technologies”, their letter said. They said speeding up hospital discharge was “just one” potential benefit from integration and indicated that “future phases” of frontrunners may focus elsewhere. But delayed discharge has been a major pressure on the system over the past year, particularly last winter, and the letter says: “Delayed discharges are one very visible signal that the health and care system remains fragmented and too often fails to deliver joined-up services that meet people’s needs.” Read full story (paywalled) Source: HSJ, 21 June 2022
  16. News Article
    Heather Lawrence was shocked at the state she found her 90-year-old mother, Violet, in when she visited her in hospital. "The bed was soaked in urine. The continence pad between her legs was also soaked in urine, the door wide open, no underwear on. It was a mixed ward as well," Heather says. "I mean there were other people in there that could have been walking up and down seeing her, with the door wide open as well. My mum, she was a very proud woman, she wouldn't have been wanted to be seen like that at all." Violet, who had dementia, was taken to Tameside General Hospital, in Greater Manchester, in May 2021, after a fall. Her health deteriorated in hospital and she developed an inflamed groin with a nasty rash stretching to her stomach - due to prolonged exposure to urine. She died a few weeks later. Heather tells BBC News: "I don't really know how to put it into words about the dignity of care. I just feel like she wasn't allowed to be given that dignity. And that's with a lot of dementia patients. I think they just fade away and appear to be insignificant, when they're not." New research, shown exclusively to BBC Radio 4's File on 4 programme, has found other dementia patients have had to endure similar indignity. Dr Katie Featherstone, from the Geller Institute of Ageing and Memory, at the University of West London, observed the continence care of dementia patients in three hospitals in England and Wales over the course a year for a study funded by the National Institute for Health and Care Research. She found patients who were not helped to go to the toilet and instead left to wet and soil themselves. "We identified what we call pad cultures - the everyday use of continence pads in the care of all people with dementia, regardless of their continence but also regardless of their independence, as a standard practice," Dr Featherstone says. Read full story Source: BBC News, 21 June 2022
  17. Content Article
    This book is a resource for the coaches who provide health IT-related assistance for primary care practices to support their QI and practice transformation efforts. The audience for this handbook includes both the health IT-focused coaches who support QI work as well as the practice facilitators/coaches who have the necessary background, interest, and skills to provide clinical health IT support. Although the handbook is primarily intended for external coaches working with primary care practices, the content could also be useful for practice-based staff responsible for addressing health IT needs related to QI. The handbook assumes readers already have a basic level of comfort with EHR use and with extracting and using electronic data for QI.
  18. News Article
    HSJ have announced the HSJ Patient Safety Awards 2022 shortlist. View the finalists here 174 projects, teams and organisations impressed the judges with their entries following a rigorous benchmarking process and have been shortlisted. The award ceremony will be held on 15 September 2022, at Manchester Central.
  19. Content Article
    The World Health Organization (WHO) Quality Toolkit provides tools to improve the quality of health services gathered together from across different programmes at WHO. This online resource is a user-friendly toolkit to support action on improving the quality of health services at every level of the health system, from national and district to facility and community levels. The Quality Toolkit accompanies the WHO Quality Health Services: a planning guide. The planning guide provides a roadmap for taking action across the health system to improve the quality of health services at the point of care, while the Quality Toolkit offers practical tools and approaches that can support implementation of the necessary actions. You can navigate the toolkit to gain a good basic understanding on quality of care, but also access practical tools that you can use in your work to enhance quality of care. This WHO toolkit will be updated regularly to ensure new resources available from WHO are included. Watch the recording of the webinar launching the toolkit here. 
  20. News Article
    Henrietta Hughes has been named as the government’s preferred candidate for the role of Patient Safety Commissioner. Sajid Javid, the Secretary of State for Health and Social Care, has today, 20 June 2022, invited the Health and Social Care Committee to hold a pre-appointment scrutiny hearing with Henrietta. Henrietta is a practising GP with a background in women’s health who was the National Guardian for the NHS until 2021. In addition to her clinical work, she is an appraiser for NHS England and Chair of Childhood First. She was selected following an open public appointment process to appoint the first Patient Safety Commissioner. Following the select committee hearing, the committee will set out its views on the candidate’s suitability for the role. The Secretary of State will then consider the committee’s report before making a final decision on the appointment. Source: Gov.UK, 20 June 2022
  21. News Article
    Women continue to file vaginal mesh lawsuits against Boston Scientific and other manufacturers, years after most products were removed from the market due to an alarming number of complications and health risks associated with the designs. In a complaint (PDF) filed last month in the U.S. District Court for the Southern District of Indiana, Tanya Davis indicates that problems with Boston Scientific Obtryx II mesh placed in her body only four years ago has left her with severe injuries, including pelvic pain and dyspareunia, abdominal pain, urinary problems, prolapse and incontinence. The lawsuit names Boston Scientific Corporation as the defendant. Transvaginal mesh products like the Obtryx II have been marketed and sold by Boston Scientific Corporation and a number of different companies over the past decade, for treatment of pelvic organ prolapse or female stress urinary incontinence. Most of the products were introduced under a controversial FDA “fast track” approval process, which allowed manufacturers to introduce new products based on the design of prior mesh, without conducting thorough research to evaluate the safety or effectiveness of the specific designs. Following widespread reports of vaginal mesh complications, including infections, erosion of the mesh into the vagina and organ perforation, the FDA required manufacturers to conduct post-marketing research and most companies decided to withdraw their products. According to the lawsuit, Davis received an Obtryx II System in May 2018, to treat her urinary incontinence. However, after experiencing painful and debilitating complications, Davis had vaginal mesh explanted in May 2020; just two years after it was implanted. “Neither Plaintiff nor her physicians and/or healthcare providers were warned that the Obtryx II was unreasonable dangerous or of the risks of the product, outlined herein, even when used exactly as intended and instructed by Defendant,” the lawsuit indicates. “To the contrary, Defendant promoted and sold the type of product implanted in the Plaintiff and thousands of women like Plaintiff, to healthcare providers as a safe alternative to other procedures that did incorporate Defendant’s products.” Read full story Source: About Lawsuits, 10 May 2022
  22. News Article
    Violence against ambulance staff in England has reached a record high, as the NHS crisis in emergency care continues to deepen. An estimated 12,626 incidents were reported in the 12 months to April 2022, according to nationwide data shared with The Independent – a 7% rise on the previous year. However, since 2016, the number of paramedics who have been verbally or physically assaulted, or threatened with assault, has nearly doubled, rising from 7,689. Adam Hopper, the national ambulance violence prevention and reduction lead for the Association of Ambulance Chief Executives (AACE), which provided the data, said the findings “confirm the worrying trend of increasing violence against ambulance staff”. One paramedic told The Independent a bone was broken in his neck after he was strangled by a drunken patient he was attempting to treat. Matthew Taylor, chief executive of the NHS Confederation, a membership body for trusts in England, said that alcohol is the most prominent factor in such assaults, followed by drugs and people being in mental health crisis. “Race and sexuality have also increased as exacerbating factors in these assaults, as have delays to treatment and arrival times,” he added. Read full story Source: The Independent, 19 June 2022
  23. News Article
    The COVID-19 crisis has both divided and galvanised Canadians on healthcare. While the last three years have presented new challenges to healthcare systems across the country, the pandemic has also exacerbated existing challenges, most notably the high levels of errors and mistreatment documented in Canadian health care. According to a 2019 report from the Canadian Patient Safety Institute, Canada was already facing a public health crisis prior to the pandemic: a crisis of patient safety. As the report details, patient safety incidents are the third leading cause of death in Canada, following cancer and heart disease. Few studies calculate national data on this topic, but a 2013 report found that patient safety events resulted in just under 28,000 deaths. Many Canadians who have experienced these errors have shared their experiences with media in an effort to raise awareness and demand change. The impact of the COVID-19 pandemic has created a moment of dual crises. First, the pre-existing crisis of patient safety, and second, healthcare overall is now at a breaking point after three years of COVID-19, according to healthcare workers. Edmonton physician Dr. Darren Markland, for example, recently closed his kidney specialist practice after making a few "profound mistakes." In an interview with Global News, he explains he could no longer work at the current pace. He is not alone in this decision. Across the country, there have been waves of resignations in health care, leaving some areas struggling with a system that is "degrading, increasingly unsafe, and often without dignity." Read full story Source: MedicalXpress, 17 June 2022
  24. Content Article
    The Government’s aim throughout the COVID-19 pandemic has been to protect the lives and livelihoods of citizens across the UK. This document sets out how the Government has and will continue to protect and support citizens by: enabling society and the economy to open up more quickly than many comparable countries; using vaccines; and supporting the NHS and social care sector. It also sets out how England will move into a new phase of managing COVID-19. The Devolved Administrations will each set out how they will manage this transition in Scotland, Wales and Northern Ireland. The global pandemic is not yet over and the Government’s Scientific Advisory Group for Emergencies (SAGE) is clear there is considerable uncertainty about the path that the pandemic will now take in the UK. This document therefore also sets out how the Government will ensure resilience, maintaining contingency capabilities to deal with a range of possible scenarios.
  25. News Article
    A clinical trial to test pregnant women for Group B Strep (GBS) – the most common cause of life-threatening infection in newborn babies – will fail unless the Government intervenes, experts have warned. Some 80 hospitals are needed for the trial to go ahead but only 32 have committed to it, with a deadline for registering of September. The trial is being funded by the National Institute for Health Research (NIHR) and will look at whether testing women for Group B Strep reduces the risk of babies dying or suffering harm. Now Dr Jane Plumb, chief executive of Group B Strep Support, who lost her son Theo to the infection, is calling on the Government and NHS England to intervene to make sure the trial goes ahead. She said: “The reality is that unless a further 48 hospitals sign up for this trial, then it will fail. “The Government is waiting for the results from this trial to determine whether to test pregnant women for Group B Strep. “Yet there seems to be little acknowledgement that this trial is heading towards failure. “We need more hospitals on board and we need to make sure that the investment in this trial is not wasted. “This is about saving the lives of babies, and it really is now or never.” Read full story Source: The Independent, 20 June 2022
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