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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    One in four older Americans covered by Medicare had some type of temporary or lasting harm during hospital stays before the COVID-19 pandemic, government investigators said in an oversight report published Thursday. The report from the U.S. Department of Health and Human Services Office of Inspector General said 12% of patients had “adverse events” that mainly led to longer hospital stays but also permanent harm, death or required life-saving intervention. Another 13% had temporary issues that could have caused further complications had hospital staff not acted. Investigators reviewed the medical records of 770 Medicare patients discharged from 629 hospitals in 2018 to formulate a national rate on how often patients were harmed, whether preventable or not. An earlier Inspector General review found 27% of patients experienced some type of harm – an investigation that led to new patient safety efforts and incentives. The incremental improvement follows intense focus on patient safety since at least 1999 when the then-Institute of Medicine published To Err is Human, a landmark report that estimated up to 98,000 deaths per year could be due to medical errors. Initiatives have since sought to improve patient safety by limiting medical errors, reducing medication mix-ups and holding hospitals with a poor record of patient safety accountable through Medicare's program to dock the pay of the worst performers on a list of safety measures. While Inspector General investigators noted improvements in certain safety measures, officials said the 25% harm rate is concerning and deserves renewed attention from hospitals and two federal agencies that oversee patient safety: the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality. "We still have a significant way to go in terms of improving patient safety," said Amy Ashcraft, a deputy regional inspector general. Read full story Source: USA Today News, 12 May 2022
  2. Content Article
    Call 4 Concern is a patient safety initiative enabling patients and families to call for immediate help and advice when they feel concerned that they are not receiving adequate clinical attention. Here is the University Hospitals Dorset Trust's leaflet.
  3. News Article
    Hundreds of organisations, including drug companies, private healthcare providers and universities, have breached patient data sharing agreements but not had their access to patient data withdrawn, a report reveals. “High risk” breaches were revealed to have occurred at healthcare groups, pharmaceutical giants and educational institutions including Virgin Care, GlaxoSmithKline (GSK) and Imperial College London, during audits by NHS Digital, according to an investigation by the BMJ. This means these organisations were handling information outside the remit agreed in data contracts and may be failing to protect confidentiality, the journal said. In one instance, local NHS commissioners allowed sensitive, identifiable patient data to be released to Virgin Care without permission from NHS Digital. When auditors tried to get access to Virgin Care to check their compliance, they were denied access for several weeks and the company refused to delete the patient data, the BMJ reported. Records about mental health, including children and young people, those with learning disabilities, diagnostic imaging and other confidential patient data was being processed outside the scope of objectives agreed with NHS Digital, at an address that had not been agreed, and without a data sharing contract. A spokesperson for Virgin Care said it had “robust data protection in place”. “It is outrageous that private companies and university research teams are failing to comply,” said Kingsley Manning, the former chair of NHS Digital. “How is it that these organisations can be so lax with data?” Read full story Source: The Guardian, 11 May 2022
  4. News Article
    Three Senegalese midwives involved in the death of a woman in labour have been found guilty of not assisting someone in danger. They received six-month suspended sentences, after Astou Sokhna died while reportedly begging for a Caesarean. Her unborn child also died. Three other midwives who were also on trial were not found guilty The case caused a national outcry with President Macky Sall ordering an investigation. Mrs Sokhna was in her 30s when she passed away at a hospital in the northern town of Louga. During her reported 20-hour labour ordeal, her pleas to doctors to carry out a Caesarean were ignored because it had not been planned in advance, local media reported. The hospital even threatened to send her away if she kept insisting on the procedure, according to the press reports. Her husband, Modou Mboup, who was in court, told the AFP news agency that bringing the case to light was necessary. "We highlighted something that all Senegalese deplore about their hospitals," "If we stand idly by, there could be other Astou Sokhnas. We have to stand up so that something like this doesn't happen again." Read full story Source: BBC News, 11 May 2022
  5. Content Article
    In a UK-first report launched in the House of Commons, leading figures from charity, healthcare, industry, law and academia have outlined a collaborative vision for UK leadership to improve maternal health. The Healthy Mum, Healthy Baby, Healthy Future: The Case for UK Leadership in the Development of Safe, Effective and Accessible Medicines for Use in Pregnancy report proposes a clear roadmap to improve the lives of millions of people, not just for women while they are pregnant, but for future generations. Over the past year, a Birmingham Health Partners led Policy Commission – co-chaired by Baroness Manningham-Buller, Co-president of Chatham House and Professor Peter Brocklehurst, University of Birmingham – has heard from key stakeholders on how best to develop safe, effective and accessible medicines for use in pregnancy. Compelling evidence gathered throughout the process has informed eight critical recommendations which, if implemented by government, will successfully prevent needless deaths and find new therapeutics to treat life-threatening conditions affecting mothers and their babies.
  6. Content Article
    During the 20th century the locus of care shifted from large institutions into the community. However, this shift was not always accompanied by liberation from restrictive practices. In 2014 a UK Supreme Court ruling on the meaning of ‘deprivation of liberty’ resulted in large numbers of older and disabled people in care homes, supported living and family homes being re-categorized as ‘detained’. Placing this ruling in its social, historical and global context, this book presents a socio-legal analysis of social care detention in the post-carceral era. Drawing from disability rights law and the meanings of ‘home’ and ‘institution’ it proposes solutions to the Cheshire West ruling’s paradoxical implications.
  7. News Article
    A new high of 6.4 million people in England were waiting for routine NHS treatment in March 2022, as 12 hours waits in A&E hit an all time high last month and ambulance services continued to struggle. This is up from 6.2 million in February and is the highest number since records began in August 2007. A new record of 24,138 people had to wait more than 12 hours in A&E after a decision to admit them had been made in April. The figure is up from 22,506 in March, and is the highest for any calendar month in records going back to August 2010. However the number of patients being seen within four hours in April improved compared to March, with 72.3% of patients seen in this time compared to 71.6%. Professor Stephen Powis, national medical director for NHS England, said: “Today’s figures show our hardworking teams across the NHS are making good progress in tackling the backlogs that have built up with record numbers of diagnostic tests and cancer checks taking place in March, as part of the most ambitious catch up plan in NHS history. “We always knew the waiting list would initially continue to grow as more people come forward for care who may have held off during the pandemic, but today’s data show the number of people waiting more than two years has fallen for the second month in a row, and the number waiting more than 18 months has gone down for the first time." Read full story Source: The Independent, 12 May 2022
  8. News Article
    A trust chief who blew the whistle on her predecessor’s ‘aggressive’ behaviour and lack of interest in patient safety says it was the hardest thing she has had to do in her career. Janelle Holmes, who is now chief executive of Wirral University Teaching Hospital Foundation Trust, was among four Wirral University Teaching Hospital Foundation Trust senior executives who wrote to regulators in 2017 about the behaviour of the trust’s then CEO David Allison. They said he would react with “dismay and aggression” to concerns being raised about service quality, and staff were afraid to speak up as a result. The intervention led to Mr Allison’s departure and a subsequent independent investigation found “deep systemic cultural issues”. Mr Allison always denied his behaviour was inappropriate. In an interview with HSJ, Ms Holmes talked of the difficulties in taking those actions, and the subsequent efforts to overhaul the trust’s culture. She said: “From a personal integrity perspective, it was the right thing to do…and I [also] felt I had a personal responsibility to make it right afterwards. “But yes, it was the most difficult thing I’ve ever had to do.” She said: “I remember watching Sir David Dalton (the ex-Salford CEO) probably more than 10 years ago… say ‘we are harming patients’.. it was like ’you can’t say that’. “But actually [there was a] complete sea change and [it became] an organisation where [speaking out] was the right thing to do. That’s the only way you can ensure you’re delivering good quality high standard services. If you’re acknowledging mistakes happen, you’re learning from them, you’re correcting things… I think that then starts to shape how our clinicians and staff feel. Read full story (paywalled) Source: HSJ, 12 May 2022
  9. News Article
    Doctors and paramedics have told the BBC that long waits for ambulances across the UK are having a "dangerous impact" on patient safety. BBC analysis found a 77% rise in the most serious safety incidents logged by paramedics in England over the past year, compared to before the pandemic. In Wales, Scotland and Northern Ireland, the 999 system is also under "tremendous pressure", doctors say. NHS England said the safety of patients is its "absolute priority". In October, nine-year-old Willow Clark fell off her bike on a country path in Hertfordshire, cracking her helmet and leaving her with a fractured skull and a nine-inch laceration across her leg. "I could see it was a really bad accident and I was 20 minutes away from home screaming for help," said her mother Sam. "These really nice people who were passing by phoned 999. "They explained she had a severe head injury and her leg was badly hurt but we were told it would be a 10-hour wait for an ambulance and we'd have to get her to hospital ourselves." When they got to A&E, Willow was immediately transferred to the trauma department. Doctors told her family that she should not have been moved because of her back and neck injuries. She later found out that Willow had been classified as an "urgent" category three case, meaning an ambulance should have arrived within 120 minutes. Coroners and lawyers have highlighted recent cases including: Staffordshire's assistant coroner issued a 'prevention of future deaths' warning after a patient in Stoke died after waiting eight hours for an ambulance. The family of a man who died after waiting nine hours for treatment has issued a legal challenge against the Northern Ireland Ambulance Service over a "chronic shortage" of ambulances. The London Ambulance service is investigating after a man died when paramedics took almost 70 minutes to respond to a suspected heart attack. Dr Katherine Henderson, an A&E consultant and president of the Royal College of Emergency Medicine, told the BBC's Today programme the problem with ambulance waits was "more serious than we've ever seen it". Read full story Source: BBC News, 12 May 2022
  10. Event
    Perioperative practitioners have worked tirelessly to rise to the challenges presented in recent years, and now continue to face the challenge of managing record-breaking waiting lists. Theatre work is challenging. You’re on your feet all day, mentally engaged and, at times, emotionally charged. This study day gives you an opportunity to focus on your own health and wellbeing as well as the welfare of your patients. "If we look after ourselves, we can look after others!" Topics will include: Review of mental health wellbeing and how to optimise it Health diet and fluid intake The benefits of exercise Optional Tai Chi taster session The importance of sleep and rest Debriefing and feedback to prevent burnout and PTSD Menopause awareness Open debate: Achieving a work-life balance in a demanding perioperative role Book
  11. News Article
    A “shocking” number of nurses from overseas are winding up “in trouble” or sanctioned within their first few months of working in the UK partly because of a lack of induction and support, a conference has heard. The issue was raised during a panel session at the Unison health conference in April discussing the importance of ethical recruitment practices in nursing and midwifery. According to Unison, it is supporting “many” overseas nurses who have been “exploited, unfairly treated and subject to racism” since their move. Among the panel was Gamu Nyasoro, a clinical skills and simulation nurse manager in the NHS and an elected member of Unison’s nursing and midwifery occupational group committee. Ms Nyasoro, who is from Zimbabwe and has been working in the NHS for the past two decades, said she herself had been discriminated against and had faced several challenges during her migration. She raised concern that overseas nurses were not given enough information about how to live and work in the UK, including about how to access healthcare services themselves, or about country specific rules and regulations. There was also the issue that UK employers “don’t look at their skills beforehand”, which means nurses were being put in roles or areas they were not confident in. She cited examples of staff who had been specialising in neonatal services before moving, who were then being asked to work with older people, and those who had been practising as a midwife in their home nations and then being required to work in emergency departments in the UK. Read full story Source: Nursing Times, 28 April 2022
  12. Content Article
    The link between nurse staffing levels and patient outcomes has been proven time and again – so why do we have a persistent shortage of nurses? Is it all due to lack of funding? And do, or should, nurses have a role in calling this out and finding solutions? These questions are explored in the latest episode of the Nursing Standard podcast, which hears from Jane Ball, professor of nursing workforce and policy at the University of Southampton, who has spent 30 years researching nurse staffing issues. She speaks about the positive impact on patient care of having the right number of nurses who are well-trained and have a good working environment.
  13. News Article
    Heart surgery patients in London have died “unnecessarily” and faced increased risk of death as botched NHS investigations into dozens of deaths reduced a hospital’s ability to treat people, a coroner has warned. “Unnecessary” patient deaths have occurred as a result of heart surgery at St George’s University Hospital Trust being restricted and emergencies diverted to other “over stretched” hospitals, following investigations by national NHS bodies. The warning that deaths have occurred and may occur in the future, comes following the conclusion of a series of inquest hearings in March, during which it was found the NHS’ wrongly blamed a team of cardiac surgeons for the deaths of dozens of patients. Coroner Fiona Wilcox, in a report published on Wednesday, has now said the “inadequate” NHS led investigations, which criticised the care of 67 patients, led to people being put increased risk of death. The NHS’ investigations into the deaths of 67 patients ruled there were “shortcomings” in care. It led to complex operations being diverted elsewhere and doctors being referred to the General Medical Council. Two doctors have sinced been exonerated following GMC hearings. According to the coroner’s findings, capacity within cardiac surgery at the unit is down by 60% and staff are becoming “deskilled.” Read full story Source: The Independent, 11 May 2022
  14. Content Article
    As you begin to see improvement in the outcomes of your QI project, you might want to think about spreading the improvement in other teams or wards, or scaling it up. However, the successful implementation of the results of an improvement project in other teams requires a well-rounded plan. This Spread and Scale Cheatsheet from LifeQI will enable you to decide whether you're ready to spread or scale the improvement and what you need to consider in both cases.
  15. Content Article
    Expanding workforce capacity, and allowing staff to recover, is going to be fundamental in achieving the ambitions set out in the elective recovery delivery plan. To help support, protect and retain staff, this letter from NHS England details a number of high impact enablers that providers should consider implementing to help improve staff experience. It also sets out a number actions being taken forward at a national level with the aim of making the workload more sustainable for staff.
  16. Community Post
    It's good to hear that you had a positive experience and you're recovering well. Many women have no pain or mild to moderate pain. However it's important hospitals follow the RCOG guidance and do offer general anaesthetic from the outset if that's what the woman wants, and stop the moment the patient is in pain. Women should be given all the information and options so they can make an informed choice. Unfortunately this isn't always the case. Thank you for sharing your experience.
  17. News Article
    “Smart socks” that track sweat levels, heart rate and motion are being given to dementia patients to alert carers if they are becoming distressed. The unintrusive technology was developed by Dr Zeke Steer, of Bristol Universit. Dr Steer wanted to find a way to spot the early warning signs of distress, so carers or relatives could intervene with calming techniques to de-escalate the situation. The hi-tech hosiery - which look and feel like normal socks - use e-textiles to transmit data in real time to an app, which alerts carers when stress levels are rising. The socks are now being trialled among mid to late stage dementia patients. Researchers think they will also help people with autism and other conditions that affect communication. Fran Ashby, manager from Garden House Care Home, in Bristol, said: “We were really impressed at the potential of assisted technology to predict impending agitation and help alert staff to intervene before it can escalate into distressed behaviours. “Using modern assistive technology examples, like smart socks, can help enable people living with dementia to retain their dignity and have better quality outcomes for their day to day life.” Read full story (paywalled) Source: The Telegraph, 9 May 2022
  18. News Article
    A nurse who filmed up the gowns of unconscious women patients and recorded staff using the toilet at a large teaching hospital has been jailed for 12 years by a judge who said he had "brought shame on an honourable profession". Paul Grayson, 51, was also told by the judge he must serve an extended licence period of 4 years when he is eventually released. The judge described how four patients were targeted as they recovered from surgery at Sheffield's Royal Hallamshire Hospital – one of whom has never been identified from the footage. Sentencing Grayson on Tuesday, Judge Jeremy Richardson QC said: "You have betrayed every ounce of trust reposed in you. Earlier this week, the court heard one victim, who was secretly filmed in the shower by Grayson over a number of years, face him directly in court as she told him his "sick and disgusting perversions" and "evil actions" were crimes that "have torn me into pieces". The court heard that one victim was unconscious after an eye operation when Grayson filmed her up her gown, and could be seen moving her underwear. The woman told police she had "put her trust in staff at the hospital to keep her safe". The victim said that she has since been due to have an operation at another hospital but she "can't bring myself to go". Read full story Source: Medscape UK, 11 May 2022
  19. News Article
    A website that tells patients how long they are likely to wait for NHS treatment will be made available in Scotland this summer. Humza Yousaf, the Scottish health secretary, said people queuing for tests and procedures and their doctors would be able to access information about any delays in their area using the software. Many patients living in pain are waiting years to have common operations such as hip and knee replacements. In theory, the SNP guarantee hospital treatment within 12 weeks of patients joining the waiting list, but this law was broken extensively before the pandemic and has now been breached hundreds of thousands of times. One orthopaedic surgeon, who did not wish to be named, said he was operating on patients whose joints had entirely collapsed after a two-year wait for a limb replacement made their case an emergency. Other patients who did not reach crisis faced even longer delays, he said. Dr Sandesh Gulhane, a GP and health spokesman for the Scottish Conservative Party, asked Yousaf, during a meeting of the Scottish Parliament’s health committee yesterday: “Why can’t we have in the future, in the [recovery] plan, indicative waiting times which are relatively live so we can all go on a website and see how long we need to wait.” Yousaf said it was fair for patients and NHS staff to expect to have information on waiting times, and that a website to provide this was being developed. “We are working closely with Public Health Scotland, we are working closely with boards to develop the infrastructure in order to collate and publish this data,” he said. “It’s an ambition of ours to have that available in a way that is easy to find, easy to understand, both for the patient but for the health professional too.” Read full story (paywalled) Source: The Times, 11 May 2022
  20. News Article
    Paramedic Moira Shaw is eyeing the frantic activity at the front doors of Edinburgh's emergency department. She is waiting for the go-ahead to hand over her patients to medics and answer the next 999 call. It can be a long wait. Last week, 1 in 10 ambulances across Scotland took more than 80 minutes to drop patients at an emergency department. BBC Scotland joined Moira and colleague Blair Paul at the Royal Infirmary of Edinburgh where they were among seven ambulances waiting to drop off patients. "At the moment we can be an hour waiting, we sit in the ambulance and we wait until there is a space to go in," explains Moira, who has been with the service for nearly a decade. "This is pretty much an everyday occurrence now. "It's that domino effect, so if patients are waiting to move to other areas, A&E gets clogged up and they can't take any more patients in because they are waiting to move people on." Moira said she has noticed they are attending more calls where people have not been able to get through to their GP so phone 999 instead. Another theme picked up by Moira and her colleague Blair is helping younger sicker patients who need urgent hospital treatment. "I've seen actually quite a lot of people maybe in their 40 or 50s who have got now stage four cancer and they've just not been able to get access to any treatments or anything just due to the pressures on the NHS at the moment," explained Blair. Read full story Source: BBC News, 11 May 2022
  21. News Article
    The culture at a long-troubled ambulance trust is ‘worsening, not improving’, its staff have told a health watchdog. Concerns about culture and patient safety at East of England Ambulance Service Trust (EEAST) were raised to inspectors at the Care Quality Commission (CQC) during an inspection of the trust last month, according to public documents. In a feedback letter to the trust following the inspection, the CQC said staffing at EEAST’s control room was below planned levels, and the inspectors were “not assured that staffing levels met the demands within the service and this may impact on patient safety when managing the high volume of calls”. The trust, which is in the equivalent of special measures and currently rated “requires improvement” by the CQC, has had long-standing cultural problems and last year signed a legal agreement with the Equality and Human Rights Commission on how it would protect staff from sexual harassment. According to the feedback letter, staff described a “worsening, not improving, culture” and said the workforce was “tired” and not receiving mandatory training, one-to-ones with managers or appraisals. The letter, published in the trust’s latest board papers, also reported inspectors raising concerns about potential risks to patients over the management of the trust’s call stack and a lack of consistency over “standard operating procedures”. Additionally, some staff in the control room on an accelerated training programme were unable to undertake full patient assessments and had to call for assistance from others. Read full story (paywalled) Source: HSJ, 11 May 2022
  22. News Article
    Covid-19 vaccines are safe for pregnant women to take and can even reduce the risk of stillbirths, according to a new study. Researchers at St George’s University of London and the Royal College of Obstetricians and Gynaecologists collated data from studies and trials involving over 115,000 vaccinated pregnant women. They found that pregnant women – who are more likely to become serious ill if they catch Covid-19 – are 15% less at risk of stillbirth if vaccinated. “We wanted to see if vaccination was safe or not for pregnant women,” said Asma Khalil, professor of obstetrics and maternal fetal medicine at London’s St George’s Hospital in London to The Guardian. “It is safe, but what’s surprising, and it’s a positive finding, is that there was a reduction in stillbirths.” “So far, most of the data on vaccines in pregnancy have been about protecting the pregnant woman herself from Covid. Now we have evidence that the vaccines protect the baby too,” she added. Read full story Source: The Independent, 10 May 2022
  23. News Article
    Relentless. Unbearable. Overwhelming. These are just some of the words used by the thousands of people who have revealed their battle with long-term, persistent pain. An exclusive survey of over 4,000 adults aged 16-75 for BBC News, carried out by research company Ipsos, suggests that a quarter of people in the UK are living with chronic pain - an often hidden and misunderstood condition. And pain specialists warn the health service is not set up to deal with such complex conditions. They say the treatments on offer are decades behind the science, leaving millions of patients without the support they need to manage their pain. Jen Proudler says chronic pain has left her grieving for "the person she was". It started four years ago with sporadic back pain. After several incorrect diagnoses, Jen was eventually told by a neurosurgeon that she had a "pretty massive" far lateral disc herniation in her spine. The pain has now spread around her body - Jen has burning pins and needles sensations down her leg, as well as sharp pain, as if being cut by a razor. Sometimes it's so bad, she can't even bear any fabric to touch it. "Our nervous system becomes more and more protective, it feels danger and sends warning signals - and those warning signals contribute to the pain," explains Dr Chris Barker, clinical director of an NHS community pain service in Ainsdale, Merseyside. He says such pain can be hard to diagnose, and the difficulty of getting the correct treatment can make things worse. "Incorrect diagnoses, delayed diagnoses, poor experiences in and out of the health system, not being believed - all of these can contribute to a more intense experience of pain." Dr Barker says the NHS is not set up to deal with such a complex condition, despite the fact it is so common. "The prevalence of pain is huge. It dwarfs most other conditions." Read full story Source: BBC News, 11 May 2022 Further reading: Is pain a patient safety issue? Blog from Patient Safety Learning
  24. Content Article
    In a fundamental sense, the vision for transforming virtual care from that of an exclusive service that benefits only a few to that of a standard for providing equitable care for all echoes the age-old debate between policy variations on the zip code and the genetic code. This commentary from Esha Ray Chaudhuri aims to further develop the key theme of engaging the “reimagining” of virtual care for older ethnic adults—by considering the syndemic nature of COVID-19 and the intersection of cultural interventions in care and equity in virtual care.
  25. News Article
    People suffering from long Covid have reacted with alarm to comments by government’s equalities watchdog that the condition should not be treated as a disability. Under the Equalities Act, anyone with a physical or mental impairment that has lasted for longer than 12 months and substantially impacted their ability to carry out normal day-to-day activities qualifies as disabled and is entitled to protection to ensure that they aren’t discriminated against in the workplace. This includes requesting that their employer makes “reasonable adjustments”, such as flexible working hours or home working, to ensure that they can continue working. In a tweet posted on Sunday night, the Equalities and Human Rights Commission (EHRC), which was set up to promote and enforce equality and non-discrimination laws said: “Discussions continue on whether ‘long Covid’ symptoms constitute a disability. Without case law or scientific consensus, EHRC does not recommend that ‘long Covid’ be treated as a disability.” The statement prompted immediate concern and confusion from long Covid support groups and unions. Dr Jenny Ceolta-Smith, an employment advocate for Long Covid Support and co-founder of Occupational Therapy for Long Covid, said: “There is already disbelief of workers’ long Covid symptoms within the workplace, and this harmful announcement by the EHRC may make it much harder for workers to gain the support that they need from colleagues and line managers. It may even mean more jobs are lost.” Read full story Source: The Guardian, 9 May 2022
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