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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    The NHS has ordered a new chair for the Nottingham maternity scandal review which is looking into hundreds of cases of alleged poor care. In a letter published late on Friday the NHS said there needed to be “urgent” changes to the way the review was being carried out and this included appointing a former NHS trust chair Julie Dent to lead the review. More than 100 bereaved families wrote to the health secretary Sajid Javid on 7 April calling for the review, to be overhauled and the chair Cathy Purt, to be replaced by Donna Ockenden who chaired the Shrewsbury maternity scandal inquiry. The Nottingham review, dubbed an “independent thematic review”, was launched in July 2021 and is being led by local NHS commissioners and NHS England. It was announced after The Independent and Channel 4 revealed millions had been paid out by the trust over 30 baby deaths and 46 incidents of babies left permanently brain damaged by Nottingham University Hospitals Foundation Trust. Sir David Sloman, the NHS chief operating officer, said in his letter on Friday: “Following discussions at both a regional and national level, it is clear that urgent changes to how the review is being delivered need to be made. A new chair needs to lead this review with sufficient senior experience to address the concerns and challenges faced at Nottingham University Hospitals, to speed up the process and to deliver a review that can bring about real change for women and babies in Nottingham. “It has therefore been agreed that the review will now have enhanced national oversight by NHS England and NHS Improvement and I am pleased to announce that Julie Dent CBE has agreed to take on the role of chair for this review and she will begin this work with immediate effect.” Read full story Source: The Independent, 23 April 2022
  2. News Article
    Pharmacy staff in England are facing growing abuse and aggression from patients frustrated that drug shortages mean they cannot get their usual medications, a survey reveals. The hostility, including swearing and spitting, comes as availability of medicines is becoming more uncertain as a result of Brexit, the Covid pandemic and ingredient supply problems. Hormone replacement therapy drugs are in short supply in many places, affecting women undergoing menopause, for example. Half of pharmacists and counter staff say the unpredictability is causing problems for customers managing their health, according to research by the Pharmaceutical Services Negotiating Committee (PSNC), which represents community pharmacies in England. The PSNC’s survey of 1,132 staff from and 418 bosses of 5,000 pharmacies found: 75% of pharmacies have seen patients turn aggressive when told they cannot have the medication they have been prescribed. 49% of staff say patient abuse is undermining their mental wellbeing. 51% believe supply chain issues affect patients every day. “It is really worrying to hear that pharmacy staff are so routinely facing aggression from patients,” said Janet Morrison, the PSNC’s chief executive. “Pharmacists tell us anecdotally that this can include verbal abuse, swearing, spitting and threatening to report staff to regulators. “Many community pharmacies are having to deal with medicine supply issues on a daily basis. This adds pressures on to already busy pharmacy teams and can also be worrying for patients if they have to wait longer for the medicines that they need.” Patients were left “frustrated and inconvenienced” by drug shortages, she added. Read full story Source: The Guardian, 25 April 2022
  3. Content Article
    Provider collaboratives are partnerships that bring together two or more NHS trusts (public providers of NHS services including hospitals and mental health services) to work together at scale to benefit their populations. While providers have worked together for many years, the move to formalise this way of working is part of a fundamental shift in the way the health and care system is organised, moving from an emphasis on organisational autonomy and competition to collaboration and partnership working. This King's Fund explainer looks at provider collaboratives in England, the opportunities they provide and the unresolved questions to consider when thinking about their role in the changing health and care landscape.
  4. Content Article
    The recent workforce race equality standard report described how staff from a Black and minority ethnic background are less well represented at senior levels of the NHS, and that they have worse day-to-day work experiences and face more challenges in progressing their careers. In this Nuffield Trust chart, Billy Palmer shows how stark some of the differences are.
  5. Content Article
    From the perspective of patient partners, the Ontario SPOR SUPPORT Unit Engaging Multi-stakeholders for Patient Oriented-research Wider Effects and Reach Awards have facilitated successful patient-partnered research projects, which, in turn, have led to an evolution in patient partnerships and engagement strategies. The 15 projects profiled in this special issue point to the beneficial impacts of patient-partnered research.
  6. News Article
    A survey looking at the effect of body image on physical and mental health has been launched by MPs in England. It also asks whether people have used the NHS to deal with body image issues and how successful services have been. The Health and Social Care Committee will use the survey as part of its ongoing inquiry into the impact of body image. The committee will hold another parliamentary evidence session on Tuesday. This session will hear from doctors, researchers and people with Body Dysmorphic Disorder. Questions in the survey cover a range of topics, including whether thoughts and feelings on body image negatively impact quality of life, and which aspects of life are affected the most. Jeremy Hunt, chairman of the Health and Social Care Committee, said: "Worries about body image can become enormously distressing, particularly for young people. "To support our inquiry into body image, we're asking people to take part in a survey about how concerns about body image can affect their physical and mental health," he added. "We want to hear about their experiences of accessing NHS services in relation to body image, whether people know where to go to get help, and whether they feel any stigma in seeking support for health issues relating to body image." Read full story Source: BBC News, 25 April 2022
  7. Content Article
    Dr Roberta Heale, Associate Editor of Evidence-Based Nursing, speaks to Dr Elaine Maxwell, Nurse and author of two National Institute for Health Research reviews on evidence on Long COVID in this BMJ Talk Medicine podcast. They discuss the variance in reported Long COVID statistics, the impact of vaccinations, symptoms, and research efforts.
  8. Content Article
    In 2016, the Centers for Disease Control and Prevention published prescribing guidelines for opioids. Though intended to encourage best practices in opioid prescribing, these guidelines fueled providers’ fears of opioids and led to many clinicians abandoning patients who relied on opioids for pain relief. In this article, Antje M. Barreveld reflects on the harms he may have caused by underprescribing these drugs, not overprescribing them.
  9. News Article
    The Health and Social Care Committee examines the Government’s progress against its pledges on the health and social care workforce and will be the focus of a new independent evaluation by the Health and Social Care Committee’s Expert Panel. Professor Dame Jane Dacre, Chair of the Expert Panel, said: “We’ll be looking at commitments the Government has made on workforce – the people who deliver the health and social care services we rely on. “We’ve identified a recurrent theme in our evaluations to date – whether in maternity, cancer or mental health services, progress is dependent on having the right number of skilled staff in the right place at the right time. Shortages have a real impact on the delivery of services and undermine achievements. “Our panel of experts will evaluate progress made to meet policy pledges in this crucial area - whether it’s about getting workforce planning right, training, or ensuring staff well-being.” The Expert Panel will focus on three areas: Planning for the workforce – including how targets are set, recruitment, and retention. Building a skilled workforce – including incorporating technology and professional development of staff. Wellbeing at work – including support services for staff, and reducing bullying rates. Four specialists have been appointed for this evaluation, bringing their subject specific expertise and experience. They will work alongside the core members of the Expert Panel in identifying a set of Government commitments on workforce and evaluate progress made against them. The findings will support the work of the Health and Social Care Committee which is carrying out a separate inquiry: Workforce: recruitment, training and retention in health and social care. Read full story Source: UK Parliament, 20 April 2022
  10. News Article
    Despite workforce being the biggest challenge facing the health service, the Health and Care Bill provides no clarity on the numbers of staff this country needs, says Andrew Goddard in a HSJ article. The Health and Care Bill returned to the Commons this week – as did the question of workforce planning. At the end of the spring term, MPs voted to reject an amendment to the bill which would have required the secretary of state to publish independent assessments of current and future workforce numbers every few years. The following week, the House of Lords – led by Baroness Cumberlege, with support from Baroness Harding, Lord Stevens of Birmingham and other cross-party peers – voted to put a revised version of the amendment back in. This particular game of ping pong about how we should plan the NHS and social care workforce is an important one. Workforce is not only a blindspot in the bill – it is a blindspot in the government’s ambitions for health and care. A lack of staff risks undermining the true potential of the Health and Social Care Levy because there will be too few staff to carry out the additional checks and diagnostic procedures promised. The new diagnostic hubs are to be staffed with existing NHS colleagues. Workforce shortages hampered our response to the pandemic and are already having a significant impact on our response to the backlog. They were also identified in the Ockenden Report as a driving factor in the avoidable deaths of 201 babies. It is concerning then, that despite workforce being the biggest challenge facing the health service, the Health and Care Bill provides no clarity on the numbers of staff this country needs. Read full story (paywalled) Source: HSJ, 22 April 2022
  11. Event
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    The Medicines and Healthcare products Regulatory Agency (MHRA) will be holding a joint virtual Innovative Licencing and Access Pathway (ILAP) information and update session. This event will provide an opportunity for patient groups and patient experts to receive an update on the work of the ILAP, how the MHRA involve patient and public representatives, and future developments about how the MHRA are accelerating the time to market and facilitating patient access to innovative medicines. This event is open to all patient and public representatives who are involved in the work of any of the ILAP partners. Along with presentations from some of the ILAP team, a patient representative will share their experiences as a member of the pilot ILAP Patient and Public Reference Group. There will also be a panel discussion session with plenty of opportunity for questions from participants. Register
  12. Event
    This one day masterclass will focus on improving patient safety by motivating staff to change behaviour and affect organisational culture. It looks at effective ways to encourage health professionals to routinely embed high quality clinical evidence into their everyday work. It will explore the characteristics of relatively successful behaviour change interventions. Key Learning Objectives: Improve patient safety by motivating staff Explore the characteristics of successful behaviour change interventions Embed high quality clinical evidence into everyday work Understand safety culture Improve motivation with staff Learn how to implement 'Nudge Theory' within your organisation. Facilitated by Mr Perbinder Grewal General & Vascular Surgeon and Human Factors & Patient Safety Trainer. Register
  13. Event
    This one day masterclass will focus on improving patient safety by motivating staff to change behaviour and affect organisational culture. It looks at effective ways to encourage health professionals to routinely embed high quality clinical evidence into their everyday work. It will explore the characteristics of relatively successful behaviour change interventions. Key Learning Objectives: Improve patient safety by motivating staff Explore the characteristics of successful behaviour change interventions Embed high quality clinical evidence into everyday work Understand safety culture Improve motivation with staff Learn how to implement 'Nudge Theory' within your organisation. Facilitated by Mr Perbinder Grewal General & Vascular Surgeon and Human Factors & Patient Safety Trainer. Register
  14. News Article
    Yet another hidden cost of Covid-19 was revealed on Thursday as the Centers for Disease Control and Prevention presented new data showing how the pandemic has dramatically impeded the US effort to vaccinate kids for other diseases. According to the CDC’s report, national vaccine coverage among American children in kindergarten dropped from 95% to below 94% in the past year – which may seem like a small amount but meant 350,000 fewer children were vaccinated against common diseases. “Overall, today’s findings support previous data showing a concerning decline in childhood immunizations that began in March 2020,” Shannon Stokley, the CDC’s immunization services deputy division director, said in a press conference on Thursday. Some of the reasons for the lower vaccination rates included reluctance to schedule appointments, reduced access to them, so-called “provisional” school enrollment, the easing of vaccination requirements for remote learners, fewer parents submitting documents and less time for school nurses to follow up with unvaccinated students. States and schools also told the CDC that there were fewer staff members to assess kindergarten vaccination coverage, and a lower response rate from schools, both due to Covid-19. “The CDC provides vaccines for nearly half of America’s children through the Vaccines for Children program,” Stokley said. “And over the last two years, orders for distribution of routine vaccines are down more than 10% compared to before the Covid-19 pandemic. “We are concerned that missed routine vaccinations could leave children vulnerable to preventable diseases like measles and whooping cough which are extremely dangerous and can be very serious, especially for babies and young children.” Read full story Source: The Guardian, 21 April 2022
  15. Event
    This conference focuses on Prehabilitation – Principles and Practice, and will provide a practical guide to delivering an effective prehabilitation programme, ensuring patients are fit and optimised for surgery/treatment. This is even more important in light of the Covid-19 pandemic and lockdowns which have had a negative effect on many individual’s health and fitness levels, and currently high waiting lists could be used as preparation time to ensure the best outcomes. The conference will look at preoperative/pre treatment optimisation of patients fitness and wellbeing through exercise, nutrition and psychological support. This conference will enable you to: Network with colleagues who are working to deliver effective prehabilitation for surgery/treatment Reflect on a patient lived experience to understand how to engage patients in prehab programmes Learn from outstanding practice in implementing a prehabilitation programme Embed virtual prehabilitation into your programme during and beyond Covid-19 Demonstrate a business case for prehabilitation and ensure prehab services continue through and beyond the pandemic Reflect on national developments and learning Improve the way we support patients to prepare themselves, physically and emotionally for surgery/treatment Develop your skills in Behaviour Change and Motivational Interviewing Embed virtual prehabilitation into your programme during and beyond Covid-19 Learn from case studies Understand how you can improve emotional and psychological support Explore the role of prehabilitation in older people Work with patients to improve nutrition Ensure you are up to date with the latest evidence Self assess and reflect on your own practice Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register
  16. Event
    Never events are defined as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.” They are designed to act as a red flag for improvement by NHS organisations. This one day masterclass will focus on safety culture around Never Events within healthcare organisations. There were 364 never events in 2020/21 and 349 between April 2021 and Jan 2022. We will look at how Never Events have been investigated and at Human Factors approaches to improving learning and the systems to reduce harm. We will compare our experiences with learning from serious incidents from other countries. Key learning objectives: Never Events Safety Culture Human Factors Learning from other countries. This masterclass is aimed at Clinical Staff and Team Leads. Register hub members can receive a 20% discount. Email: info@pslhub.org for the code.
  17. Content Article
    Chen et al. examined the worldwide prevalence of post COVID-19 condition, through a systematic review and meta-analysis. The research, published in the Journal of Infectious Disease, assessed 23 symptoms reported across 36 of the studies and found that shortness of breath, sleep problems, and joint pain was widely reported by those who had recovered from the novel coronavirus infection. They analysed the prevalence of this condition globally and regionally, estimating the proportion of individuals facing long Covid in Asia, Europe and North America. They found that the global prevalence for post-Covid conditions at 30, 60, 90 and 120 days after infection was about 37, 25, 32, and 49%, respectively. The authors concluded that post COVID-19 condition prevalence is substantial; the health effects of COVID-19 appear to be prolonged and can exert stress on the healthcare system.
  18. News Article
    An analysis of data from 50 studies looking at 1.6 million people suggests that as much as 43% of those infected with the coronavirus experienced post-Covid conditions, pointing to the need for better diagnosis and care for “long Covid” patients. Post-Covid conditions are clinically defined by the World Health Organization (WHO) as mid- and long-term symptoms – also known as Long Covid – occurring in individuals after infection with the SARS-CoV-2 virus. The research, published this week in the Journal of Infectious Disease, assessed 23 symptoms reported across 36 of the studies and found that shortness of breath, sleep problems, and joint pain was widely reported by those who had recovered from the novel coronavirus infection. Researchers say fatigue (23%) and memory problems (14%) were the most common symptoms of individuals experiencing post-Covid conditions. While about 34% of non-hospitalised coronavirus patients report lingering post-Covid symptoms, scientists say this rate jumps to over 50% for hospitalised Covid patients. “Long Covid is quite common overall and across geographic regions, sex and acute COVID-19 severity. Knowing this, providers should take proactive approaches such that their patients are well-supported when experiencing long-term health effects of Covid-19,” scientists wrote in the study. Read full story Source: The Independent, 21 April 2022
  19. News Article
    Women are being left unable to sleep or work competently because of the shortages of hormone replacement therapy (HRT) products used to treat symptoms of the menopause, the former cabinet minister, Caroline Nokes, has said. Millions of women go through the menopause every year, with many experiencing symptoms that can be severe, such as low mood, anxiety, hot flushes and difficulty sleeping, and have a negative impact on everyday life. The number of prescriptions for HRT in England has doubled in the last five years to more than 500,000 a month. But the rise in prescriptions has come amid several years of HRT shortages, with pharmacists often unable to fulfil prescriptions. Shortages have been blamed on manufacturing and supply issues, and have been exacerbated by the growing numbers of women seeking the products. Speaking in the Commons on Thursday, Nokes, chair of the women and equalities committee, called for an urgent debate on the issue to ensure women “can get the supplies that we need”. In October, the government announced that the cost of repeat prescriptions for HRT would be significantly reduced in England. In the Commons on Thursday, Labour MP Nick Smith asked Spencer why there was “no date yet for the HRT prescription changes in England”. Spencer said it was “something the health secretary is looking at, at this moment in time”. Read full story Source: The Guardian, 21 April 2022
  20. News Article
    Analysis of thousands of tumours has unveiled a treasure trove of clues about the causes of cancer, representing a significant step towards the personalisation of treatment, a study suggests. Researchers say that for the first time it is possible to detect patterns – called mutational signatures – in the DNA of cancers. These provide clues including about whether a patient has had past exposure to environmental causes of cancer such as smoking or UV light, for example. This is important as these signatures allow doctors to look at each patient’s tumour and match it to specific treatments and medications. Dr Andrea Degasperi, research associate at the University of Cambridge and first author, said: “Whole genome sequencing gives us a total picture of all the mutations that have contributed to each person’s cancer. “With thousands of mutations per cancer, we have unprecedented power to look for commonalities and differences across NHS patients, and in doing so we uncovered 58 new mutational signatures and broadened our knowledge of cancer.” The findings are now being incorporated into the NHS as researchers and clinicians now have the use of a digital tool called FitMS that will help them identify the mutational signature and potentially inform cancer management more effectively. Read full story Source: The Independent, 21 April 2022 You may also be interested to read hub blog: Genetic profiling and precision medicine – the future of cancer treatment
  21. News Article
    The NHS is falling behind in the race to tackle antibiotic-resistant infections, with the service set to miss two key targets. As part of the government’s 2019 five-year-action plan to tackle the growth in antimicrobial resistance (AMR), the NHS was set the target of reducing the number of healthcare-associated bloodstream infections of three gram-negative bacteria by 25% by March this year, and 50% by the end of March 2024. Infections caused by E. coli, pseudomonas aeruginosa and klebsiella can cause urine or wound infection, blood poisoning or pneumonia. The AMR action plan said: “In the UK, the biggest drivers of resistance [include] a rise in the incidence of infections, particularly gram-negatives.” Last week, health and social care secretary Sajd Javid stressed the continuing importance of the issue, stating that antimicrobial resistance is “one of the biggest health threats facing the world”. Analysis by HSJ has shown there has been only a small decline in the numbers of cases involving the three bacteria since monitoring started. The baseline for measuring the reduction was 2016-17, when there were 23,037 healthcare associated infections related to the bacteria. Read full story (paywalled) Source: HSJ, 21 April 2022
  22. News Article
    A hospital for adults with eating disorders has been rated inadequate after inspectors found the provision of food was "unsafe and unacceptable". A Care Quality Commission (CQC) report of the Schoen Clinic in York said some patients were given mouldy bread and one was served food containing plastic. Concerns were also raised around lack of staff and patient safety, though wards were clean and well-equipped. Schoen Clinic Group said issues raised in the report "were quickly addressed". Following the inspection in January the hospital has been placed in special measures and will be visited again in six months. Brian Cranna, CQC's head of hospital inspection, said: "The standards of care we found at Schoen Clinic York were putting patients at risk and so we have taken urgent enforcement action, which means the service must improve if it's to retain its registration." According to the report patients were put at risk of "physical and psychological harm due to unsafe and unacceptable food provision". Read full story Source: BBC News, 21 April 2022
  23. Content Article
    In patient experience research, participants frequently report the impact that mesothelioma has on their mental health yet there have been very few studies specifically focused on mental health and mesothelioma. In patient experience research, participants frequently report the impact that mesothelioma has on their mental health yet there have been very few studies specifically focused on mental health and mesothelioma. This new study from the Mesothelioma UK research centre aims to create an understanding of the impact of mesothelioma on the mental health of patients, their families and close friends, and what people do to improve their mental health and well-being.
  24. Content Article
    Keren Levy was fit and healthy when she first felt pain in a molar. After numerous dentists and doctors left it untreated, there were knock-on effects throughout her body. Today she is in constant pain and look almost unrecognisable She went to the dentist a number of times but X-rays showed nothing untoward. However, Karen started to develop a horribly rotting taste and knew the tooth was necrotic. She begged her dentist to give her root canal treatment or extract it, but without a visible sign this was needed she was refused. Instead she was referred to her GP, implying her distress was bereavement due to her mother recently dying. Many months later, Keren was referred to a different dentist who gave her a 3D scan that showed the original tooth to be necrotic, as she had said five months before. Evidence of the infection was clear in the surrounding bone. Her dentist records that the delay in treating the original dental infection appears to have triggered a systemic response in my body’s autonomic or endocrine system. Having had perfect health, eventually I had to have 12 root canals; all those teeth were necrotic.  Confronted by the facts, the first dentist Keren saw said that, had he been in his Athens surgery, he would have carried out a root canal on the original tooth. But here, in the UK, he had been concerned he could be held to account by General Dental Council (GDC) regulations, given the X-ray image had not been “definitive”.  An editorial in the British Dental Journal (BDJ) as long ago as 2014 described a climate of “fear and distrust” that had led to defensive dentistry because of the prospect of legal action or disciplinary procedures if anything goes wrong.  Karen's case is a horrific example of excessive diagnostic testing delay, instead of treatment. Months of referrals to neurologists, maxillo-facial specialists, psychologists, GPs, oral medicine departments and other dentists went against common sense and ensured responsibility could never be laid at a particular dentist’s door. Invariably, the first question was: “What did the last dentist say?”
  25. Content Article
    David Hencke in this issue of Westminster Confidential discusses the avoidable death scandal at Epsom and St Helier University Health Trust that has led to another relative coming forward and queries about a former senior staff member in Jersey.
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