Jump to content
 View Profile  See their activity

  • Posts

    11,589

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

Everything posted by Patient Safety Learning

  1. Content Article
    AcciMap graphically maps the multiple contributing factors to an accident and their inter-relationships onto the following six levels: Government policy and budgeting. Regulatory bodies and associations. Local health economy planning and budgeting (including hospital management). Technical and operational management. Events, processes and conditions. Outcomes.
  2. Content Article
    An expert committee will extend the vision for the nursing profession into 2030 and chart a path for the nursing profession to help create a culture of health, reduce health disparities, and improve the health and well-being of the US population in the 21st century. The committee will consider newly emerging evidence related to the COVID-19 global pandemic and include recommendations regarding the role of nurses in responding to the crisis created by a pandemic.
  3. Content Article
    Presentation on the of theme of prevention of medication error from Philip A Routledge and James Coulson (All Wales Therapeutics and Toxicology Centre). Presentation available as slides a written transcript.
  4. Community Post
    An investigation by The Sunday Times has found that the drug sodium valproate is still being handed out to women in plain packets with the information leaflets missing, or with stickers over the warnings. Sodium valproate, has been given to women with epilepsy for decades without proper warnings, and has caused autism, learning difficulties and physical deformities in up to 20,000 babies in Britain. The government is refusing to offer any compensation to those affected by sodium valproate, despite an independent review by Baroness Cumberlege concluding in 2020 that families should be given financial redress. Read the Twitter thread from Rebecca Bromley who has been working with families who have suffered:
  5. News Article
    Volunteers will transport patients who need extra assistance to hospital to increase ambulance availability for higher-risk patients. The pilot scheme, using ambulance cars, is due to start in London in May. London Ambulance Service said the trained volunteers would be sent to lower category 999 calls where the patient needed help to get to hospital. The service's board meeting was told the scheme would reduce waiting times and increase ambulance availability. Currently, taxis are used to transport "low acuity patients" to hospital, the meeting heard. But there were some patients who required "the assistance of one person to walk or mobilise", which taxis could not provide. "This results in the dispatch of an emergency ambulance, reducing ambulance availability for higher priority incidents and longer waiting times for patients," the meeting heard. As part of the pilot scheme, a volunteer car would be dispatched to these patients. A spokesperson for the service said: "This project builds on our well-established network of volunteers who respond to emergencies to help ensure our ambulances can reach the patients that need us the most. "These fully trained volunteers, who already respond to 999 calls in their communities, will help patients who have been assessed not to need of an ambulance but who may need more support than a taxi can provide." Read full story Source: BBC News, 18 April 2022
  6. News Article
    NHS leaders are urging people to attend vital lung cancer check-ups as figures reveal almost two-thirds of those invited are not coming forward. The NHS targeted lung health check service offered in some parts of England aims to help diagnose cancer at an earlier stage when treatment may be more successful. Current and former smokers aged between 55 and 74 are invited to speak to a healthcare professional and, if they have a higher chance of developing lung cancer, are offered a scan of their lungs. Doctors are keen to reach those who may not have sought help for symptoms during the pandemic and could be living with undiagnosed lung cancer. People diagnosed at the earliest stage are nearly 20 times more likely to survive for five years than those whose cancer is caught late, according to the NHS. The NHS has already diagnosed 600 people with the disease in travelling trucks, which visit convenient community sites across the UK, such as supermarkets and sports centres, aiming to make it easier for people to access check-ups. But figures show only a third (35%) of patients go to their lung health check when invited by the NHS. “These lung checks can save lives,” said Dame Cally Palmer, the NHS cancer director. “By going out into communities we find more people who may not have otherwise realised they have lung cancer, with hundreds already diagnosed and hundreds of thousands due to be invited." Read full story Source: The Guardian, 19 April 2022
  7. News Article
    The UK medicines watchdog has been urged to strengthen its conflict of interest policy after it emerged that six of its board members are receiving payments from the pharmaceutical industry. Board members involved in overseeing the regulator’s “strategic direction” also have financial interests in companies including US and Saudi drug giants and firms with ambitions to break into the UK’s healthcare market. Some offer consultancy services while others help run or own shares in drug and medical device firms, according to official transparency records. There is no suggestion of wrongdoing, but the findings have led to concerns about perceived conflicts of interest among senior figures at the Medicines and Healthcare products Regulatory Agency (MHRA), an executive agency of the Department of Health and Social Care responsible for regulating drugs and medical devices and ensuring they are safe. The MHRA said that “in order to be an effective regulator” it needed to “bring together the right expertise from across industry, academia, the public and beyond”, adding that board meetings are held in public and non-executive board members – to whom the potential conflicts relate – are not involved in “any work or decisions relating to the regulation of any products”. But critics raised concerns about the potential for bias – or the perception of it – and called for stricter rules on conflicts of interest for those working in pharmaceutical regulation. Read full story Source: The Guardian, 17 April 2022
  8. News Article
    The moment her newborn son Sebastian was handed to her, Catherine McNamara knew something was terribly wrong. His tiny hands were deformed, unnaturally twisted and facing in the wrong direction. One was missing a thumb. A few days later, the couple were devastated as doctors told them Sebastian’s deformities were permanent — and had been caused by the drug McNamara had been taking to control her epilepsy. Like thousands of women, McNamara had been told her epilepsy medicine, sodium valproate, was safe to take during pregnancy. “They told me everything would be fine,” she said. Sodium valproate, which was given to women with epilepsy for decades without proper warnings, has caused autism, learning difficulties and physical deformities in up to 20,000 babies in Britain. Yet despite a 2020 report that criticised the failure over four decades to inform women about the dangers, doctors are still not properly warning women of the risks. According to the latest data, published in March, sodium valproate was prescribed to 247 pregnant women between April 2018 and September 2021. An investigation by The Sunday Times has found that the drug is still being handed out to women in plain packets with the information leaflets missing, or with stickers over the warnings. The government is refusing to offer any compensation to those affected by sodium valproate, despite an independent review by Baroness Cumberlege concluding in 2020 that families should be given financial redress. The former health secretary Jeremy Hunt says doctors should now be banned from prescribing the drug to pregnant women — and that the families affected by it must be properly compensated. He has compared the case to the scandal of the anti-morning-sickness drug thalidomide, which caused deformities in thousands of babies after it was licensed in the UK in the 1950s. Read full story (paywalled) Source: The Sunday Times, 16 April 2022
  9. News Article
    Trusts leaders can expect more emphasis on inspection ratings for individual services in future — as opposed to overall organisational ratings — the chief executive of the Care Quality Commission has said. In an interview with HSJ, Ian Trenholm discussed the future of the inspection regime, his views on prosecuting trusts, and how integrated care systems could be regulated. Asked about the future of inspections, Mr Trenholm said he did not believe trust leaders would be satisfied with just looking at their overall rating. He said: “My appeal to chief executives would be look at the broader suite of services that you’ve got in front of you. “In [the] future, I think there’ll be much more emphasis on individual ratings of individual services. Exactly what the detail will look like I think remains to be seen…” It follows questions about the accuracy of NHS acute trust ratings now, with the CQC having carried out fewer thorough inspections during the pandemic. There is now only one trust rated “inadequate”, despite huge concerns about service failings, particularly in acute care. He said the “intention over the next few months” is to create a new CQC single assessment framework which incorporates inspection findings for health systems, as well as individual providers." Read full story Source: HSJ, 19 April 2022
  10. Content Article
    The Royal Society's science and the law programme brings together scientists and members of the judiciary to discuss and debate key areas of common interest and to ensure the best scientific guidance is available to the courts.  The judicial primers project is a unique collaboration between members of the judiciary, the Royal Society and the Royal Society of Edinburgh. Designed to assist the judiciary when handling scientific evidence in the courtroom, the primers have been written by leading scientists, peer reviewed by practitioners, and approved by the Councils of the Royal Society and the Royal Society of Edinburgh. Each primer presents an easily understood and accurate position on the scientific topic in question, as well as considering the limitations of the science, challenges associated with its application and an explanation of how the scientific area is used within the judicial system. The primers are created under the direction of a Steering Group chaired by Dame Anne Rafferty and distributed to courts in conjunction with the Judicial College, the Judicial Institute, and the Judicial Studies Board for Northern Ireland.
  11. Content Article
    Health systems in low and middle income countries (LMIC) are increasingly pluralistic, involving a wide mix of public, not-for-profit and for-profit providers. Regulation should be a key foundation of the Government's stewardship role of these heterogeneous facilities, but performance of this function is generally weak, with serious consequence for patient safety and quality of care. There has been little evaluation of strategies to strengthen regulation in LMIC, a notable exception being the Kenya Patient Safety Impact Evaluation (KePSIE), a collaboration between the Kenyan Ministry of Health and the World Bank. This randomised controlled trial is assessing the impact of a set of innovative regulatory interventions in public and private facilities in three Kenyan counties. These comprise the use of the Joint Health Inspections Checklist (JHIC), which synthesises the areas covered by all the regulatory Boards and Councils; increased inspection frequency; risk-based inspections where warnings, sanctions and time to re-inspection depend on inspection scores; and display of regulatory results outside facilities. The KePSIE trial will provide a rigorous quantitative assessment of these regulatory strategies.  The results are expected to make an important contribution to the limited evidence base on regulation and regulatory reform. The findings will be of substantial benefit to those concerned with regulatory reform and the improvement of quality and safety more generally in Kenya and other LMIC settings.
  12. Content Article
    After two years under siege from COVID, many nurses in the United States are reconsidering the profession.
  13. News Article
    A clinical director and several senior managers have written to a trust CEO warning that patients are routinely waiting more than 60 hours to be admitted to a ward from accident and emergency, leaving staff “crying with frustration and anger”. In a letter to executives at Lancashire Teaching Hospitals Foundation Trust, seen by HSJ, the managers say they lack support from the rest of the trust, and claim the emergency department at Royal Preston Hospital has a “never-ending elasticity in the eyes of others”. The letter, dated 30 March, is signed by clinical director Graham Ellis, two unit managers, the specialty business manager, and the matron. It says: “Whilst we have documented our concerns previously the current situation is worse than it has ever been…Our situation is increasingly precarious… “For the past few months we have on a regular basis had more than 50 patients waiting for a bed and that wait being in excess of 60 hours. “This means that at most times there is limited or no space to accommodate newly acutely ill patients causing ambulance handover delays of over four hours and delay in treatment.” Clinicians at Preston have been raising safety concerns about the ED for several years, but the letter is the first time concerns of senior managers have been made public. The letter references research which suggests patients die as a “direct result from long waits in ED”, and says there has been an increase in clinical incidents, pressure sores, detrimental outcomes, and occasions where patients “die without the dignity of privacy”. Read full story (paywalled) Source: HSJ, 4 April 2022
  14. News Article
    NHS bosses have written to hospitals telling them to stop using language that implies a bias against caesarean sections when advertising jobs in maternity services. A recent report into an NHS maternity scandal found that a focus on “normal birth” had played a key role in babies dying or being born disabled. Women at the Shrewsbury and Telford trust were forced to undergo traumatic natural births when they should have been offered surgical intervention. However, even since its publication, trusts have published job adverts looking for a member of staff “to help us promote normality” or saying that they are “proud of our commitment to normal birth”. In a letter sent, Dr Matthew Jolly, NHS clinical director for maternity, and Professor Jacqueline Dunkley-Bent, chief midwifery officer, ask maternity services “to review the language that they are using about their services, in job adverts, and any other information designed to support decision-making on pregnancy and birth choices”. The letter continues: “There have been a number of concerns raised about the language used in some NHS trust maternity service job adverts and materials — phrases that suggest bias toward one mode of birth. “The NHS has a duty to provide safe and personalised care to women and families according to best practice guidance informed by evidence and the changes that are taking place in society, midwifery, maternity, and neonatal care services. “It is a fundamental requirement of a maternity multidisciplinary team to inform and listen to every woman, respect their views and help them to try and achieve the type of birth they aspire to.” Read full story (paywalled) Source: The Times, 15 April 2022
  15. News Article
    A doctor from North Lanarkshire has been found guilty of 54 sex offence charges against women over 35 years. Krishna Singh, 72, kissed, groped, gave inappropriate examinations and made sleazy comments to 48 patients during appointments in various medical settings. Prosecutors described how the sexual predator was "hiding in plain sight" over nearly four decades. The offences mainly occurred at medical practices in North Lanarkshire, but also at a hospital accident and emergency department, a police station and during visits to patients' homes. An investigation was launched into his behaviour when one woman reported him to authorities in 2018. A letter was then sent to all patients at the practice to see if they could help in the police inquiry. Many women became so uncomfortable going to see the GP that they brought a friend or relative to appointments. One woman tried to make her medication last longer to delay having to go back and see him. Prosecutor Angela Gray told the jury during the trial that Singh had been in a routine of abusing his position to offend against women. She said: "Sexual offending was part of his working life. Access to women as and when the situation arose and taking the chances when he could." Read full story Source: BBC News, 14 April 2022
  16. News Article
    The chief executive of a mental health trust grappling with care quality failures has described his anger at ‘disrespectful’ staff who have ‘now had to leave the organisation’. In a message to staff, seen by HSJ, Brent Kilmurray, chief executive of Tees Esk and Wear Valleys Foundation Trust, said a number of staff had “stepped away from our values”. HSJ has heard reports of 12 staff members within the trust’s forensic secure inpatient services being suspended in recent weeks, and some dismissed, after being caught sleeping on shifts and using electronic devices while meant to be observing patients. The reports are unconfirmed, but appear to be referenced in a message sent by Brent Kilmurray on 14 March, which said: “I’m sorry to say, there’s been a handful of people who have stepped away from our values and in doing so have now had to leave the organisation." Mr Kilmurray said the staff were in a “minority” and that when the trust investigated these matters “we have found far more excellent caring practice”. He added the trust is working with service leaders “to ensure that they understand their accountabilities for ensuring that services are safe”. Read full story (paywalled) Source: HSJ, 14 April 2022
  17. News Article
    Operations are being cancelled across England as Covid causes “major disruption” inside the NHS, the country’s top surgeon has said, as doctors and health leaders say the government’s backlog targets look increasingly unachievable. Six million people are on the waiting list for NHS hospital care, including more than 23,000 who have waited more than two years. Boris Johnson said in February that he had launched “the biggest catch-up programme in the history of the health service”, but in the same month he dropped every domestic Covid restriction. Now record-high Covid rates are wreaking havoc with the ability of the NHS to catch up with surgery that was delayed or cancelled before and during the pandemic. More than 28,000 staff are off work every day due to Covid, recent figures show, while more than 20,000 patients are in hospital with Covid, which has dramatically reduced the number of beds and space available for planned surgery patients. “Unfortunately, Covid-19 continues to cause major disruption in the NHS, with high staff absences in recent weeks,” Prof Neil Mortensen, the president of the Royal College of Surgeons of England, told the Guardian. “We have heard that planned surgery is being cancelled again in different parts of the country due to staff being off sick with the virus. This is understandably frustrating for surgical teams who want to help their patients by getting planned surgery up and running again. It’s also very distressing for patients who need a planned operation.” Read full story Source: The Guardian, 14 April 2022
  18. News Article
    Five thousand nurses at Stanford and Lucile Packard children’s hospital in Stanford, California, are preparing to strike in demand of wage increases, mental health and wellness support, better healthcare benefits, and a focus on hiring and retaining nurse staff. The union has set a strike date for 25 April. Stanford hospital at Stanford University in California has been consistently ranked among the top hospitals in the US by US News, but nurses say high turnover rates, understaffing, and inadequate proposed wage increases and benefits have contributed to high burnout rates. In a survey of union members, 45% of nurses reporting said they intend to leave their job within the next five years. Kathy Stormberg, a nurse in the radiology department at Stanford hospital for 19 years and vice-president of the Committee for Recognition of Nursing Achievement (Crona), blamed the strike on the hospitals’ continued reliance on contractors and its policy of pushing nurses to work overtime amid staff shortages, unfilled vacancies, and difficulties retaining enough nursing staff. “That is not sustainable,” said Stormberg. “Nurses have an overwhelming sense of guilt to work overtime when they are getting texts requesting nurses to come in every four hours on their days off.” In January 2022, a nurse on a contract at Stanford hospital walked out of their shift and killed themself, highlighting the need for better mental health and wellness support services and for improvements to the poor working conditions that nurses have faced through the Covid-19 pandemic. “The working conditions that we have now are just no longer sustainable,” said Leah McFadden, a nurse in Stanford’s surgical trauma unit since October 2019. “Over the last two years, we’re starting to run on empty, we aren’t having a chance to decompress, or even just get away from the hospital as much as we should.” Read full story Source: The Guardian, 13 April 2022
  19. Content Article
    The delivery of safe and effective healthcare to paediatric and neonatal patients presents unique challenges to the medication-use system. The diversity of patients within this population and the consequences of ontogeny on pharmacokinetics and pharmacodynamics directly impact the safe use of medications in children and increase the risk of adverse drug events. This review from Elkeshawi et al. will explore the medication-use system for hospitalised children and neonates, discuss vulnerabilities within this system, and provide examples of advancements made to improve the paediatric medication-use system.
  20. Content Article
    Medication safety events with the potential for patient harm do occur in healthcare settings. Pharmacists are regularly tasked with utilizing their medication knowledge to optimize the medication-use process and reduce the likelihood of error. To prepare for these responsibilities in professional practice, it is important to introduce patient safety principles during educational experiences. The Accreditation Council for Pharmacy Education (ACPE) and the American Society of Health-System Pharmacists (ASHP) have set forth accreditation standards focused on the management of medication-use processes to ensure these competencies during pharmacy didactic learning and postgraduate training. The experience described here provides perspective on educational and experiential opportunities across the continuum of pharmacy education, with a focus on a relationship between a college of pharmacy and healthcare system. Various activities, including discussions, medication event reviews, audits, and continuous quality improvement efforts, have provided the experiences to achieve standards for these pharmacy learners. These activities support a culture of safety from early training.
  21. News Article
    A California appeals court has upheld a lower court ruling that Johnson & Johnson must pay penalties to the state for deceptively marketing pelvic mesh implants for women, but reduced the amount by $42 million to $302 million. Johnson & Johnson had appealed in 2020 after Superior Court Judge Eddie Sturgeon assessed the $344 million in penalties against Johnson & Johnson subsidiary Ethicon. Sturgeon found after a non-jury trial that the company made misleading and potentially harmful statements in hundreds of thousands of advertisements and instructional brochures for nearly two decades. The instructions for use in all of the company’s pelvic mesh implant packages "falsified or omitted the full range, severity, duration, and cause of complications associated with Ethicon’s pelvic mesh products, as well as the potential irreversibility and catastrophic consequences," Presiding Justice Judith McConnell of the appeals court said in a 3-0 ruling upholding the $302 million in penalties. The products, also called transvaginal mesh, are synthetic and surgically implanted through the vagina of women whose pelvic organs have sagged or who suffered from stress urinary incontinence when they cough, sneeze or lift heavy objects. Many women have sued the New Jersey-based company alleging that the mesh caused severe pain, bleeding, infections, discomfort during intercourse and the need for removal surgery. Read full story Source: Fox News, 12 April 2022
  22. News Article
    NHS leaders are warning that the health service is facing the "brutal reality" of an Easter as bad as most winters. Latest data shows record waits for planned surgery and in A&E, as staff plough through a backlog fuelled by Covid. The government says there is hope on the horizon. Jean Shepherd, 87, had a stroke in April last year, leaving her severely disabled and requiring round-the-clock care. At the end of February there was an outbreak of sickness at her nursing home and she needed hospital treatment. She had to wait in a wheelchair for more than 9 hours until an ambulance arrived to take her to A&E. She then spent 31 hours on a trolley between the emergency department and a secondary-care unit. "She was very distressed because she doesn't like hospitals at the best of time," says her son, Andy Shepherd. "Since the stroke, because of her cognitive ability, she doesn't understand what's happening around her." Mrs Shepherd was eventually moved to a bed in a main hospital ward, where her family says she later contracted Covid, before recovering and being discharged back to her care home two weeks later. "I appreciate that A&E departments have always been busy, but I just wasn't prepared for what greeted me at the hospital," says her son. "There were patients on ambulance trolleys literally everywhere and the staff were absolutely rushed off their feet. I remember thinking at the time that this is not sustainable." Read full story Source: BBC News, 14 April 2022
  23. News Article
    A trust board has backed the medical director who oversaw the dismissal of a whistleblower in a case linked to patient deaths. Portsmouth Hospitals University Trust told HSJ John Knighton had the full support of the organisation when asked if he faced any censure over the wrongful dismissal of a consultant who raised the alarm about a surgical technique. Jasna Macanovic last month won her employment tribunal against the trust with the judge calling its conduct “very one-sided, reflecting a determination to remove [her] as the source of the problem”. The judgment found that the disciplinary process Dr Knighton oversaw was “a foregone conclusion” and as such had broken employment rules. The nephrologist was twice offered the opportunity to resign with a good reference, once during her disciplinary hearing and again on the day the outcome of that hearing was delivered. The trust told HSJ nothing in the judgment suggested Dr Knighton should face any action about his conduct and none had been taken. It said there were no reasons to doubt his credibility or probity. The trust did not respond when asked if any apology had been offered to Dr Macanovic. A spokesperson said: “We are committed to supporting colleagues raising concerns, so they are treated fairly with compassion and respect.” Read full story (paywalled) Source: HSJ, 13 April 2022
  24. News Article
    There has been a dramatic fall in morale among midwives across multiple measures within the NHS staff survey. Although general morale deteriorated among most staffing groups in 2021, the results for midwives across numerous key measures have worsened to a far greater degree than average. It comes amid the final Ockenden report into the maternity care scandal at Shrewsbury and Telford Hospitals Trust, which raised serious concerns about short staffing and people wanting to leave the profession. The survey results, published on 31 March, suggest 52% of midwives are thinking about leaving their organisation, up 16 percentage points on the previous year. In comparison, the number of general nurses thinking of leaving was 33%, up just 5 percentage points. Chris Graham, chief executive of healthcare charity the Picker Institute, which coordinates the staff survey, described the midwifery profession as an “outlier” in the 2021 results, in terms of how their experiences compare to other groups and how their responses have changed over time. “Not only do midwives report worse experiences in many areas, but there is evidence of particularly sharp declines in some key measures,” Mr Graham said. “It appears likely that staffing shortages are a major factor here.” Read full story (paywalled) Source: HSJ, 13 April 2022
  25. Content Article
    The Ockenden review of maternity services at Shrewsbury and Telford NHS Trust uncovered the biggest maternity scandal in the NHS’s history. The report concludes that 201 babies and nine mothers might have survived if they had received better care and raises serious questions about how avoidable deaths and injury to so many mothers and babies could have happened  Staffing pressures, training gaps, and overstretched rotas all contributed. But so did a failure to follow clinical guidelines or to investigate and learn from mistakes. Staff did not listen to patient experience, women were blamed or held responsible for poor outcomes—even their own deaths—and there was a lack of compassion in how patients were treated and responded to. Inadequate leadership and a bullying culture left staff feeling unable to raise concerns or escalate problems Is there a failure to listen to women across the NHS? Why are women’s voices ignored and their health concerns brushed aside?
×
×
  • Create New...