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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Martha Hickey and colleagues argue that social and cultural attitudes contribute to the varied experience of menopause and that medicalisation fuels negative perceptions.
  2. News Article
    There’s little question that US hospitals—up against COVID, patient surges, and labor and supply shortages—have become less safe for patients during the pandemic, as preventable events and complications have become more common. Leaders with the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) said as much, earlier this year, in an article for the New England Journal of Medicine: “Many indicators make it clear that health care safety has declined,” they wrote, noting, “the fact that the pandemic degraded patient safety so quickly and severely suggests that our health care system lacks a sufficiently resilient safety culture and infrastructure.” Despite such frank assessments, CMS is now at odds with public safety advocates about whether to make some of the hospital-specific data behind those trends publicly available. Read full story (paywalled) Source: Fortune, 14 June 2022
  3. News Article
    Bristol's NHS commissioning group is one of many across the country which is "causing harm" to people with thyroid problems by limiting the provision of a drug, a new report says. Analysis from the Thyroid Trust says that 58 per cent of NHS Clinical Commissioning Groups in England are withdrawing, refusing or reducing prescriptions of T3 for people with underactive thyroids - against national guidance. People who have thyroid problems can suffer from depression, crippling fatigue, weight gain and muscle weakness, which can be alleviated by the drug. But the Bristol, North Somerset and South Gloucestershire CCG does not permit prescribing the drug for new patients, according to the report. One Westcountry woman told the Express that she had her T3 prescription withdrawn, which caused her significant problems. Former police officer Carole Morgan-Anstee, 62, told the website she went through "hell" after her T3 was stopped. The Somerset woman was prescribed the drug after suffering symptoms including chronic fatigue and hair loss for 15 years. But after being treated with T3 for five years, her endocrinologist told her he had been ordered to stop prescribing it for her. He reportedly said the problem was that her local Bristol North Somerset and South Gloucestershire CCG had began cutting back on T3 supplies. Carole said: "I was really upset. It was hell. My treatment was completely within the guidelines and he knew how ill I would get if they took it away. The Thyroid Trust report says: "Around the country most Clinical Commissioning Groups have policies in place which are causing harm to patients by denying treatment. In those cases where this has occurred, patients have resorted to the private sector or to informal means, such as buying the medication online, or even travelling abroad where it is sometimes available to buy over the counter, to source the medicine they need which the NHS should be providing. Read full story Source: Bristol Post, 15 June 2022
  4. News Article
    Severe restrictions imposed on care home residents in Scotland during the Covid pandemic caused "harm and distress" and may have contributed to some deaths, academics have said. A 143-page report has been produced by Edinburgh Napier University. It had been commissioned by the independent inquiry into the country's handling of the pandemic. The report says that the legal basis for confining residents to their rooms and banning visitors was "unclear". And it said care home residents were arguably discriminated against compared to other citizens. The report is 1 of 14 that have been published by the Scottish Covid-19 Inquiry, which is chaired by Lady Poole. It found that in the early months of the pandemic there was "little evidence" that the human rights of residents and their families had been considered. It said: "There is substantial evidence of the harm and distress caused to residents and their families by the restrictions imposed in care homes. "This includes concerns that, particularly for people with dementia, being unable to maintain contact with their family exacerbated cognitive and emotional decline, potentially hastening their death." Read full story Source: BBC News, 16 June 2022
  5. Content Article
    The Inquiry is investigating the Covid-19 pandemic in Scotland. The Inquiry will establish the facts about the devolved response to the Covid-19 pandemic, in order to identify what lessons there are for the future.  The aim is to learn from the handling of the Covid-19 pandemic. People in Scotland have suffered as a result of Covid-19. The Inquiry will examine what was done to face the challenge of the pandemic. The Inquiry will report on what worked well, areas where things could have been done better, and make recommendations. 
  6. News Article
    Only half of healthcare professionals feel they have sufficient tools to manage the long-term damage that sickle cell disease brings, new research has revealed. The in-depth study by Global Blood Therapeutics - carried out across 10 countries including the UK, US and Canada - shows that patients living with the illness remain dramatically underserved by healthcare systems, while healthcare professionals don’t feel like they have the knowledge of the disease or their patients, to properly treat them. More than two in five (43%) doctors and nurses cited difficulties due to having different ethnic backgrounds from their patients, it was revealed, while almost three quarters (73%) stated patients of lower economic status can be more difficult to treat. Almost a third of healthcare professionals (31%) found it challenging to understand their patients’ needs. Sebastian Stachowiak, Head of Europe and GCC at Global Blood Therapeutics, told The Independent that the survey “confirms the lack of options for physicians” and expressed hope that, with recent advances in available treatment, patients can be better served in the future. The study also found that almost half (46%) of patients say that emergency room healthcare providers did not believe them about their symptoms, while 48% said that they have been treated like a drug seeker in the emergency room. Read full story Source: The Independent, 14 June 2022
  7. News Article
    Two drugs that combat superbugs are being introduced on the NHS, offering a lifeline to thousands of patients with deadly infections such as sepsis which fail to respond to antibiotics. About 65,000 people a year in the UK develop drug-resistant infections and 12,000 die, many after routine operations or from infections such as pneumonia or urinary tract infections. These superbugs such as MRSA have mutated to develop resistance to many different types of antibiotics as a result of overuse of the drugs. It means patients end up dying from common infections that would previously have been easily treatable with antibiotics. In a attempt to “turn the tide” on antibiotic resistance, the NHS has announced a deal for two drugs, cefiderocol and ceftazidime–avibactam, which can kill bacteria that is resistant to many other types of drugs. The drugs, manufactured by Shionogi and Pfizer respectively, will save the lives of about 1,700 patients a year. They will be offered to patients with conditions such as drug-resistant pneumonia, sepsis or tuberculosis who have run out of other treatment options. Amanda Pritchard, NHS chief executive, said this would make the UK a world leader in tackling “the global challenge of antimicrobial resistance”. Read full story (paywalled) Source: The Times, 15 June 2022
  8. News Article
    Delays unloading ambulances at busy hospitals are causing serious harm to patients, a safety watchdog is warning. The Healthcare Safety Investigation Branch has been investigating how the long waits are delaying 999 emergency response times across England. Kenneth Shadbolt, 94, waited more than five hours for an ambulance after a bad fall - an accident that proved fatal. Logs show that in his final 999 call he asked: "Can you please tell them to hurry up or I shall be dead." Ken Shadbolt had been in good shape for his age. On the night of Wednesday, 23 March 2022, just before 03:00, he got out of bed to go the bathroom and fell, hitting a wardrobe before collapsing on the floor. He had hurt his hip - how badly he didn't know - and couldn't get up. He could reach his mobile on his bedside, though, and dialled 999 for help. The BBC has seen transcripts of the three separate phone calls he made to South Western Ambulance Service that night. The first was short and factual, covering the basic details of his injury. He seemed calm and lucid but made clear he was in pain and needed an ambulance. Internal call logs seen by the BBC show that at this point Ken was triaged as a category two emergency, meaning paramedics should arrive in 18 minutes, on average. About 15 minutes later, Ken called 999 for a second time. An internal ambulance service log seen by the BBC shows that South Western Ambulance Service was indeed busy that night. It talks about "high demand" in the Gloucester area, with more than 60 patients waiting for help, some for more than eight hours. Another hour passed before Ken made his third and final call to 999. It was clear now that he was in serious pain. He felt "terrible sick" and said his "breathing is going too". "I need an ambulance because I'm going to fade away quite quickly," he said. The same reply came back: "The ambulance service is just under a lot of pressure at the moment... we are doing our best." An ambulance finally got to Kenneth Shadbolt's house at 08:10 that morning, four hours after that final call. Ken died at 14:21 that afternoon, with the cause of death given as a "very large subdural haematoma" or bleed on the brain. His son Jerry Shadbolt said: "The doctors were saying his injuries were non-survivable but would they have been non-survivable if he'd arrived at hospital four hours earlier? I'd like an answer to that question. "He was on his own and he knew he was on his own. He must have felt abandoned and alone on his bedroom floor. That's the most troubling part of it for me." Read full story Source: BBC News, 16 June 2022
  9. News Article
    The NHS is facing a major exodus of doctors of ethnic minority backgrounds due to persistent levels of racism faced at a personal and institutional level, a ground breaking study has revealed. Nearly one third of doctors surveyed have considered leaving the NHS or have already left within the past two years due to race discrimination, with 42 per cent of Black and 41 per cent Asian doctors in particular having considered leaving or having left. The survey paints a picture of institutional barriers to career progression, dangerously low levels of reporting of racist incidents and a growing mental health burden on ethnic minority doctors. With more than 2,000 responses from doctors and medical students across the UK, the BMA – a professional association representing all doctors in the UK – believes that this survey is one of the largest of its kind to document the experience of racism in the medical profession and workplace. Dr Chaand Nagpaul, BMA chair of council, said: “The NHS was built on the principle of equality of care for patients whoever they are, but this report shows that the NHS is shamefully failing in this principle for its own doctors, with those from ethnic minorities reporting alarming levels of unfair treatment and racial inequality at work. Read full story Source: The Independent, 15 June 2022
  10. Content Article
    This report presents the findings of the British Medical Association (BMA) racism in medicine survey, which ran from October to December 2021. The survey sought to gather evidence of the racism experienced by doctors and medical students working in the NHS, and the impact of these experiences on their working lives and their career opportunities. All doctors and medical students in the UK, from all ethnic backgrounds, were invited to participate. The survey received 2030 responses in total, making it one of the largest of its kind. It found a concerning level of racism in the medical profession, stemming from fellow doctors, other NHS staff, and patients. These experiences of racism present in a variety of forms in the institutions and structures of the medical profession
  11. News Article
    The NHS has a low bed base, and NHS England is reviewing ‘how we right-size our capacity’ across hospital, community and ‘virtual’ services, Amanda Pritchard has said. The NHSE chief executive addressed the annual NHS Confederation this week and said: “The NHS has long had one of the lowest bed bases among comparable health systems. And in many respects this reflects on our efficiency and our drives to deliver better care in the community. “But it was true before the pandemic, and it remains true now that we have passed the point at which that efficiency actually becomes inefficient. “So the point has come where we need to review how we right-size our capacity across the NHS. That will of course look at the whole picture of hospital, community and virtual capacity.” Ms Pritchard also highlighted the current pressures on the emergency care system, which has widely been linked to slow discharges from hospital and insufficient social care provision. She cited the “unacceptable rise in 12-hour waits for admission from [accident and emergency]” which “underlines that the issue is flow”, and said “we know we will need to make more progress before winter”. Read full story (paywalled) Source: HSJ, 15 June 2022
  12. Content Article
    Covid-19 may be receding, but it’s leaving a quiet menace lurking in hospitals in its wake. In a Perspective essay in The New England Journal of Medicine, four senior physicians with the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention warned of a “severe” post-Covid decline in patient safety. The Association for Professionals in Infection Control and Epidemiology reached a similar conclusion, warning of a rise in “common, often-deadly” infections. To help reverse this troubling trend, the federal physician leaders called for “promoting radical transparency.”  In this article, Michael L. Millenson and J. Matthew Austin discuss how adapting the psychological principles of 'Maslow’s Hierarchy of Needs' as an organising framework, paired with the principles of information design, can significantly boost both the use and impact of safety and quality information.
  13. Content Article
    The National Institute for Health and Care Research (NIHR) is funding a portfolio of research to improve our understanding of, and find treatments for, Long Covid. The NIHR’s 19 studies are trying to answer some of the most urgent questions.
  14. Content Article
    Benjamin King lived 5-days before parents, Jamie Thomas King and Tamara Podemski, had to pull him off life support. Benjamin's parents share their experience, the value of sharing their story with the media and what changes have happened in UK hospitals since to ensure this won't happen to any other family. The panel discusses the role of human factors and system design and how it can be embraced to ramp up patient safety improvement. Human factors experts across healthcare and aviation will discuss this issue alongside patient advocates who have lost loved ones where the application of principles and methodologies of human factors engineering may have saved their loved ones lives. Hear from the leadership at Christus Muguerza Hospital Sur in Monterrey, Mexico, about their work to become an HRO Champion.
  15. News Article
    A family in Texas is suing a Houston-based doctor after their 4-year-old on son underwent an "unintended vasectomy" during a surgery. The child was reportedly in the hospital for a hernia surgery at the time of the incident, according to Randy Sorrels, the family's personal injury attorney. He told Fox4 that part of the procedure involved work near the child's groin. The attorney claimed the surgeon "cut the wrong piece of anatomy." “The surgeon, we think, cut accidentally the vas deferens, one of the tubes that carries reproductive semen in it. It could affect this young man for the rest of his life,” Mr Sorrels told the broadcaster. The surgeon who operated on the boy has no history of malpractice and has otherwise never received any negative reports on their work. Mistakes like the one made on the toddler are generally very rare due to safety precautions built into the surgery process. “It’s not a common mistake at all,” Mr Sorrels said. “Before a doctor transects or cuts any part of the anatomy, they are supposed to positively identify what that anatomy is and then cut. Here, the doctor failed to accurately identify the anatomy that needed to be cut. Unfortunately, cut his vas deferens. That wasn’t found out until it was sent in for pathology.” The attorney said his and the family’s top concern is for the boy’s health. They are considering options for reversing the procedure, but the attorney noted that doing so would require the boy to undergo more surgery. Read full story Source: The Independent, 15 June 2022
  16. News Article
    The language used around childbirth should be less judgemental and more personal, a report led by midwives has found. Most women consulted said terms such as "normal birth" should not be used, it says. The report recommends asking pregnant women what language feels right for them. Maternity care has been under the spotlight after a recent review found failures had led to baby deaths. The new guidance "puts women's choices at its heart, so that they are in the driving seat when it comes to how their labour and birth are described", Royal College of Midwives chief executive Gill Walton said. About 1,500 women who had given birth in the past five years gave their views. Most preferred the term "spontaneous vaginal birth" to "normal birth", "natural birth" or "unassisted birth". Words suggesting "failure", "incompetence" or "lack of maternal effort" should also be avoided, they said. They wanted labour and birth to be a positive experience and for the language used to be non-judgemental, accurate and clear. Read full story Source: BBC News, 15 June 2022
  17. News Article
    One of the trusts worst affected by coronavirus has been issued with two warning notices and rated ‘inadequate’ for leadership, following a Care Quality Commission inspection. The regulator raised serious concerns about the safety of Countess of Chester Hospital Foundation Trust’s maternity services, as well as the oversight and learning from incidents. It also found staff were experiencing multiple problems with a newly installed electronic patient record, while systems for managing the elective waiting list were said to be unsuitable. In maternity services, the inspectors flagged severe staff shortages and a failure to properly investigate safety incidents. They said there were three occasions during the inspections when the antenatal and post-natal ward was served by only one midwife, despite the interim head of midwifery saying this would never happen. Inspectors also highlighted five incidents last year where women had suffered a major post-partum haemorrhage, involving the loss of more than two litres of blood and which resulted in an unplanned hysterectomy. The CQC said two were not reported as serious incidents, and where learning had been identified from the others, action plans were not being completed on time. The CQC said it was only made aware of the incidents by a whistleblower, while internal actions agreed in December 2021 had still not been implemented two months later. Read full story (paywalled) Source: HSJ, 15 June 2022
  18. News Article
    A review intended to drive ‘rapid improvements’ to maternity services in Nottingham has been scrapped after just eight months – with some bereaved families saying instead it did ‘irreparable’ damage to their mental health and trust in the system. It was hoped the process would lead to rapid change, restore families’ faith in maternity in Nottingham, and provide a voice for parents who wanted to share both positive and negative experiences. Instead, some families said they found the review process slow, unprepared for the number of people who came forward and lacking the impact needed to improve a maternity service rated ‘inadequate’ by health inspectors. The growing frustration that followed would turn to anger for some families, leading to the direct involvement of a Government minister, the arrival and rapid departure of a new chair, and the eventual disbanding of the review altogether in favour of a fresh start with one of the country’s top advisers on midwifery, Donna Ockenden – who led an in-depth review into Shrewsbury and Telford NHS Trust’s maternity services. The U-turn came after pressure from a group of more than 100 people named ‘Families Harmed by Nottingham Maternity’ – which includes parents whose babies have died or been injured while being cared for at Nottingham’s two main hospitals. Local Democracy Reporter Anna Whittaker looks at what led to so many families turning on a system which the NHS said was set up to bring about major changes. Read full story Source: Notts, 14 June 2022
  19. Content Article
    This strategy sets out the Secretary of State for Health and Social Care’s vision for how data will be used to improve the health and care of the population in a safe, trusted and transparent way. It: provides an overarching narrative and action plan to address the current cultural, behavioural and structural barriers in the system, with the ultimate goal of having a health and care system that is underpinned by high-quality and readily available data marks the next steps of the discussion about how we can best utilise data for the benefit of patients, service users, and the health and care system This strategy applies to England only. The strategy shows how data will be used to bring benefits to all parts of health and social care – from patients and care users to staff on the frontline and pioneers driving the most cutting-edge research. It is backed by a series of concrete commitments, including: investing in secure data environments to power life-saving research and treatments using technology to allow staff to spend more quality time with patients giving people better access to their own data through shared care records and the NHS App.
  20. Content Article
    A new multinational survey, on more than 1,300 patients, caregivers and healthcare professionals in 10 countries, shines a needed light on the misunderstood realities, unseen burden and care challenges of sickle cell disease. The Sickle Cell Health Awareness, Perspectives and Experiences (SHAPE) survey, one of the largest global burden of disease surveys conducted in sickle cell disease, identified long-term health complications of sickle cell disease as a key concern among 1,300 patients and healthcare professionals surveyed from 10 countries The survey also revealed that sickle cell disease patients' caregivers face profound physical, psychosocial, and economic burdens resulting from taking care of people living with the disease. The findings of the survey were presented during a poster presentation at the European Hematology Association (EHA) 2022 Hybrid Congress. “Sickle cell disease is a lifelong condition that causes damage in the body and has a profound impact on the quality of life of those who suffer from it and their caregivers. The SHAPE survey is important because it illustrates how vital it is that we understand our patients’ needs, and it suggests what we within the medical community can do to help change perspectives, increase education and awareness, and improve care,” said Dr. Baba Inusa, professor and consultant of paediatric haematology, Guy’s and St Thomas’ NHS Foundation Trust, London and chair of the National Haemoglobinopathy Panel in England. “These results are a wake-up call, and I believe that the actions that follow can enable us to help drive a better dialogue and improved conversations around the management and care of this long-neglected and devastating disease.”
  21. Event
    From July 2022, all NHS trusts providing acute and mental health services will need to join a provider collaborative, with these collaboratives forming a universal part of the provider landscape. Working within a challenging NHS environment – struggling with record high waiting lists and a limited workforce – provider collaboratives offer an opportunity to make efficiencies whilst improving service delivery. As providers move from a mindset of competition to one of collaboration, they must come together to deliver better services and improve care pathways. However, the purpose and form of these collaboratives can vary considerably across England and important decisions remain over the governance and accountability arrangements of these new collaboratives. Join the King's Fund for this digital virtual conference 12–15 September which will bring together leaders from across collaboratives to explore this new approach to service delivery. The event will explore what collaboration models have been successful before and the barriers they overcame. What can we learn from these as new collaboratives are set to take shape? Register
  22. Event
    This masterclass will cover the new guidance and provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide advice on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Anyone with responsibility for implementing the duty of candour should attend, whether as a health or social care professional or at an organisational level, be it in the NHS, private healthcare or social care. Health and social care professionals; staff with responsibility for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending. See flyer attached below: Implementing the Duty of Candour with Empathy generic leaflet.pdf For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/duty-of-candour or click on the title above or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for a discount code.
  23. Event
    This masterclass will cover the new guidance and provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide advice on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Anyone with responsibility for implementing the duty of candour should attend, whether as a health or social care professional or at an organisational level, be it in the NHS, private healthcare or social care. Health and social care professionals; staff with responsibility for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending. See flyer attached below: Implementing the Duty of Candour with Empathy generic leaflet.pdf For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/duty-of-candour or click on the title above or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for a discount code.
  24. Content Article
    In every aspect of our lives, language matters – and in health and care settings, it’s even more important. How we communicate with each other can determine the quality and impact of the care given and received, which is why developing a shared language is so important. Pregnancy and birth are extraordinarily personal, and personalising care is central to good outcomes and experience. There has been a great deal of debate in recent years about the language around birth, and the impact it can have. During this project from the Royal College of Midwives, for example, women said terms such as ‘failure to progress’ or ‘lack of maternal effort’ can contribute to feelings of failure and trauma. There has been particular debate around the term ‘normal birth’. Despite being the term used by organisations including the International Confederation of Midwives and the World Health Organization, it has often taken on negative connotations in the UK, and particularly in England. In 2020, the Royal College of Midwives, which counts the majority of midwives practising in the UK among its membership, took the decision to address this, and to try to develop an agreed shared language, working with maternity staff, users of maternity services and others involved in the care and support of pregnant women and families. Over the course of 18 months, the consultation has involved nearly 8,000 people from across all four UK nations. How we use language inevitably evolves over time, but the Re:Birth project will help to embed a shared, respectful way of discussing labour and birth.
  25. News Article
    The chief executive of one of the first teaching trusts in the country to have eliminated two-year waiters for elective care has said there is ‘no magic to it’ and it can be replicated elsewhere. Since the beginning of April, University Hospitals of Coventry and Warwickshire Trust has reported zero patients waiting over two years for their elective treatment – ahead of NHS England’s target of July 2022. According to the latest data, there are now 42 trusts that have eliminated 104-week waits and UHCW is the largest trust to have done this. UHCW chief executive Andy Hardy said that in order to achieve this the trust had been “relentless” in its focus on waiting times and had set up “bootcamps” to help managers understand how referral to treatment works. Mr Hardy said in an interview with HSJ: “It really does come down to a laser-like focus on waiting times, both at an executive level, down to a group level, and down to speciality level. It can be replicated. There’s no magic to it.” He said: “We use data to drive our organisations away from bad decisions and I have a weekly access meeting with the chief operating officer to look at where we are against all access targets, but obviously we focus on waiting times." Read full story (paywalled) Source: HSJ, 15 June 2022
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