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. News Article
    Gynaecology waiting lists in England have risen by 60% during the pandemic - more sharply than any other specialty. Across the UK, more than 570,000 women are waiting for help. The Royal College of Obstetricians and Gynaecologists (RCOG) said patients were "consistently deprioritised and overlooked". NHS England says hospitals are making progress on dealing with the Covid backlog and average waiting times for elective treatment are coming down. The RCOG is calling for much greater attention to women's views, and for care to be designed around their needs. Chetna Mistry says she is a "prisoner" to endometriosis, a painful condition in which tissue similar to the lining of the womb grows in other places, like the ovaries. She described it as "a whole-body disease which affects you physically and mentally". It has left her infertile, and, at 42, she needs a hysterectomy. Chetna said she was referred to a specialist in June 2020, but 21 months later still does not have a date for surgery. RCOG president Dr Edward Morris said he felt helpless not being able to speed up access to care for women and people on his waiting lists. "There is an element of gender bias in the system. I don't think believe that we are listening to voices of women as well as we should be. The priority they urgently need is not being given to them." The Royal College asked 830 women on waiting lists about the other impacts on their lives. Read full story Source: BBC News, 4 April 2022
  2. News Article
    Patients visiting Wales' newest emergency department were likely to have been put at risk of harm due to the lack of processes and systems in place, inspectors found. Healthcare Inspectorate Wales (HIW) carried out an unannounced inspection of The Grange University Hospital in Cwmbran between 1 and 3 November last year and published its findings on 29 March. On the day of their arrival inspectors said The Grange was at full capacity with no empty beds in A&E or in the hospital in general. Despite the best efforts of staff who were "working hard under pressure" the report stated the emergency department had several issues which could have compromised the privacy and dignity of patients. This included problems with the physical environment of the waiting room, which was described as a "major cause of anxiety" for visitors, as well as with the flow of patients through the hospital in general. It found that patients were not triaged and medically managed in A&E in a timely fashion with many being placed on uncomfortable chairs or in corridors for hours on end. Between 1 April 2021 and 1 November 2021, the average waiting time in the department was six hours and seven minutes. The report said some issues required immediate action including the fact patients in the waiting area were often left to "deteriorate without being overseen". There were also infection control failures which could have led to the cross-contamination of Covid-19. "We were not assured that all the processes and systems in place were sufficient to ensure that patients consistently received an acceptable standard of safe and effective care," the report stated. Read full story Source: Wales Online, 1 April 2022
  3. News Article
    ‘Horrifying and upsetting’ reports of bullying in prestigious heart units are being probed by national officials and professional leaders, HSJ can reveal. Health Education England told HSJ it was “undertaking a national thematic review of training in cardiothoracic surgery”, while the Society for Cardiothoracic Surgery separately revealed it was investigating concerns about “bullying, harassment and undermining behaviour” in the specialty following high-profile recent cases in Newcastle and Wales. Society president consultant surgeon Simon Kendall, who is based at James Cook University Hospital in Middlesbrough, told HSJ he has been made aware of wider problems beyond those identified in the North East and Wales. Mr Kendall revealed allegations reported to the society have included people being shouted at in public, problems resulting from a “legacy culture of sarcasm and public humiliation”, and more personal disputes between individuals. The consultant surgeon told HSJ: “The job is hard enough for all of us, without picking on each other and making it worse." He added: “It’s the extended team that is affected by these behaviours and it will have an impact on patient safety and patient care. Read full story (paywalled) Source: HSJ, 1 April 2022
  4. Content Article
    Developing an organisational approach to improvement in healthcare is a journey that can take several years. It requires corporate investment in infrastructure, staff capability and culture over the long-term. These resources from NHS Providers explain why organisation-wide improvement in healthcare matters, and how to get started.
  5. Content Article
    Learn how to change important behaviours in your personal or professional life in this course from UCL.
  6. Content Article
    This duty of candour animation offers guidance on the importance of being open and honest. Being open and honest with patients and those close to them is always the right thing to do and is often referred to as the duty of candour. NHS Resolution have produced a short animation to help those working in health and social care to better understand the similarities and differences that exist between the professional and statutory duties of candour. The 8-minute animation also offers guidance on how they can be fulfilled effectively.
  7. Content Article
    In the 1790s, François Marie Prevost, a young French surgeon fresh from his medical training in Paris moved to Port-de-Paix, Haiti. “Of course at that time Haiti was France's most economically valuable colony”, says historian Deirdre Cooper Owens. “So there he began some experimental work on enslaved Haitian women, trying to perfect the caesarean section.” Prevost's sojourn coincided with the leadership of Toussaint Louverture, who had been born a slave, the fight for Haitian independence, and the abolition of slavery. And so Prevost left Haiti for Louisiana. “He moved to a little town outside of Baton Rouge, and began experimental surgery on enslaved women there, perfecting the caesarean section, and he did this in the 1830s, the era before the civil war that ends slavery.” It was also an era in which Louisiana surgeons were reluctant to attempt the experimental surgery on white women. Of the 15 caesarean sections done by Prevost and others in Louisiana between 1820 and 1861, all were performed on enslaved women. “At the time, in the 19th century, during the time of slavery, they couldn’t consent”, she explains. “But this is the really interesting thing: from the 1830s all the way to the 21st century, Louisiana has been in the top three states with the most caesarean sections on Black women patients…So what's going on, did all of these women need to have caesarean sections?”
  8. Content Article
    We need to make community-powered prevention a valued part of the system, writes Prof Donna Hall in this HSJ article. Mark Spencer is a GP who has completely reinvented his role. Tired of sitting in his surgery day after day prescribing medicines to the same people with the same conditions, he decided to get out into the communityand talk to them about what needed to change. The result is Healthier Fleetwood - a remarkable flowering of multiple community-led groups. The groups cover a wide range of issues from men’s mental health to obesity. But they all share one thing in common - they use the power of human connection and support to prevent illness in the first place rather than simply manage it. This is why there are groups dedicated simply to singing or crafts as a way of keeping people mentally and physically healthy, as well as those more directly focused on “conditions”. The results speak for themselves - reduced obesity, falling admissions to accident and emergency (pre-covid), and a doubling of GP numbers made possible by more sustainable finances. And, most importantly, dozens of stories of people’s lives transformed, even saved.
  9. Content Article
    More and more people have been asking for a return to normal, and with omicron waning, governments are starting to act. The UK is removing its remaining public health measures, including mandatory self-isolation of COVID cases and free testing. However, the inescapable truth is that – unless the virus mutates to a milder form – the “normal” life we are returning to will be shorter and sicker on average than before. This article in The Conversation looks at how we need to live post-Covid.
  10. Content Article
    This book interrogates the assumption that evidence means the same thing to different constituencies and in different contexts by outlining a more nuanced and socially responsive approach to medical expertise that incorporates scientific and lay processes of making sense of the world and deciding how to act in it. In so doing, it provides a point of orientation for clinicians working at the coalface, whose experience is sometimes at odds with the type of rationality that underpins evidence-based medicine and that guides researchers conducting randomised controlled trials. The argument elaborated also has implications for policy makers in the healthcare system, who have to navigate similar pressures and contradictions between scientific and lay rationality to produce meaningful guidelines in the midst of a runaway pandemic. Debates within and beyond the medical establishment on the efficacy of measures such as mandatory face masks and lockdowns are examined in detail, as are various degrees of hesitancy towards vaccines and other pharmaceutical interventions. The authors demonstrate that it is ultimately through narratives that knowledge about medical and other phenomena is communicated to others, enters the public space, and provokes discussion and disagreements. Importantly, effective narratives can enhance the reception of that knowledge and reduce some of the sources of resistance and misunderstanding that continue to plague public communication about important medical issues such as pandemics. Access the introduction and excerpts from each chapter from the link below.
  11. Gallery Image
    Which drug is which?
    Ondansetron, metoclopramide and oxytocin. Which is which? Very different drugs but very similar bottles and labels.
  12. Event
    until
    The perioperative environment is complex and rapidly changing with a diverse, multi-professional workforce. A global shortage of perioperative practitioners has forced us to ‘bridge the gap’ by working collaboratively across many boundaries and specialities to deliver safe, high-quality patient care. This study day from the Association for Perioperative Practice (AfPP) explores how embracing a multi-professional approach to perioperative care can help us to build theatre teams that are fit for the future. From Anaesthetists to Registered Operating Department Practitioners (RODPs) and Registered Nurses (RNs), there are many transferable skills across perioperative professions. Our speakers will identify some of these transferable skills, explore the lessons we can learn from our multi-disciplinary colleagues, and examine four key areas of practice. The goal is to provide you with evidence-based practice that can be taken back to your workplace to further educate the multi-professional team and facilitate changes in practice to improve patient safety and reduce never events. Topics include: Lessons learnt as a consultant anaesthetist. Potential barriers to preventing harm. Recognising and managing difficult airways. Inadvertent hyperthermia prevention and management. ‘Not Just Small Adults’ – paediatric perioperative care. Safe manual handling and patient positioning. Transferrable skills – from RODP to management. Register
  13. Event
    This one day course from the Royal College of Surgeons of Edinburgh will teach junior surgical trainees fundamental knowledge of vascular emergencies and investigations, as well as basic vascular suturing skills irrespective of their specialty. Through lectures, interactive discussion and practical skills stations, participants should be able to assess vascular emergencies, interpret vascular investigations and formulate possible treatment options, perform end-to-end, end-to-side anastomosis as well as vein patch and embolectomy by the end of the course. Register
  14. Event
    This innovative educational initiative from the Royal College of Surgeons of Edinburgh was developed as a direct and constructive response to the communication inadequacies exposed by the Montgomery case, and subsequent legislation. While it is not difficult to give ‘more information’ it is harder for surgeons and patients to achieve a decision partnership. The ICONS workshop content has been informed by internationally recognised experts in Shared Decision Making, by consensus among senior practising surgeons, by patients and by professional experts in risk management and risk communication. Delegates on the ICONS workshops will acquire skills and knowledge to implement best practice in sharing the complex decisions surrounding informed consent. By participating in a workshop, they will also contribute to the development of resources for future training in the important area of informed consent. Register
  15. Event
    This innovative educational initiative from the Royal College of Surgeons of Edinburgh was developed as a direct and constructive response to the communication inadequacies exposed by the Montgomery case, and subsequent legislation. While it is not difficult to give ‘more information’ it is harder for surgeons and patients to achieve a decision partnership. The ICONS workshop content has been informed by internationally recognised experts in Shared Decision Making, by consensus among senior practising surgeons, by patients and by professional experts in risk management and risk communication. Delegates on the ICONS workshops will acquire skills and knowledge to implement best practice in sharing the complex decisions surrounding informed consent. By participating in a workshop, they will also contribute to the development of resources for future training in the important area of informed consent. Register
  16. Content Article
    This World Health Organization (WHO) guideline aims to improve the quality of essential, routine postnatal care for women and newborns with the ultimate goal of improving maternal and newborn health and well-being. It recognises a “positive postnatal experience” as a significant end point for all women giving birth and their newborns, laying the platform for improved short- and long-term health and well-being. A positive postnatal experience is defined as one in which women, newborns, partners, parents, caregivers and families receive information, reassurance and support in a consistent manner from motivated health workers; where a resourced and flexible health system recognises the needs of women and babies, and respects their cultural context. This is a consolidated guideline of new and existing recommendations on routine postnatal care for women and newborns receiving facility- or community-based postnatal care in any resource setting.
  17. Content Article
    This Health Foundation long read explores how the NHS in England can better use routine health data to help address current challenges, including winter pressures, the ongoing coronavirus response and the growing elective care backlog. It examines the longstanding barriers to widespread use of data and data science, consider what actions might help to overcome these, and explore whether the data strategy for health and social care will deliver the change needed.
  18. News Article
    Poor culture and leadership must be addressed if we are to make our maternity services the safest place to give birth. This statement from the Royal College of Midwives (RCM) came as the final report of the largest ever review of NHS maternity services was published. The RCM acknowledged that the pain and suffering of the families had been worsened by having to fight for answers and vowed to work with NHS bodies and other professional organisations to ensure lessons are learned from these tragic failings. Today the RCM has pledged to continue its work to be part of the solution to safety improvements and support its members to do the same not only at Shrewsbury and Telford NHS Trust, but throughout all maternity services across the UK. Commenting, the Royal College of Midwives’ (RCM) Chief Executive, Gill Walton said: “It is heartbreaking that this report only came about because of the determination of the families. We owe them a debt that I fear can never be repaid. What we can do - all of us who are involved in maternity services – is work together to ensure we listen, and we learn from this and ensure that women and families have trust in their care." “This review must be a turning point for all those working in maternity services. The actions recommended are measured and sensible and reflect much of what the RCM has been calling for. We hope that those in a position to enact them – NHS England and the Department for Health & Social Care – will do so in partnership with organisations like ours and with haste.” "A poor working culture, where staff were afraid to raise concerns, has been cited by the report as a key factor in many of the cases. Earlier this year the RCM called for a seismic NHS cultural shift to improve maternity safety as it published guidance for its members to raise concerns about maternity care which outlined steps staff can take and what to do if they feel they are not being listened to or their concerns are ignored." Read full story Source: Royal College of Midwives, 30 March 2022
  19. News Article
    It has long been clear that Black Americans have experienced high rates of coronavirus infection, hospitalisation and death throughout the pandemic. But those factors are now leading experts to sound the alarm about what will may come next: a prevalence of Long Covid in the Black community and a lack of access to treatment. Long Covid — with chronic symptoms like fatigue, cognitive problems and others that linger for months after an acute coronavirus infection has cleared up — has perplexed researchers, and many are working hard to find a treatment for people experiencing it. But health experts warn that crucial data is missing: Black Americans have not been sufficiently included in Long-Covid trials, treatment programmes and registries, according to the authors of a new report released on Tuesday. “We expect there are going to be greater barriers to access the resources and services available for Long Covid,” said one of the authors, Dr. Marcella Nunez-Smith, who is the director of Yale University’s health equity office and a former chair of President Biden’s health equity task force. “The pandemic isn’t over, it isn’t over for anyone,” Dr. Nunez-Smith said. “But the reality is, it’s certainly not over in Black America.” In the first three months of the pandemic, the average weekly case rate per 100,000 Black Americans was 36.2, compared with 12.5 for white Americans, the authors write. The Black hospitalisation rate was 12.6 per 100,000 people, compared with 4 per 100,000 for white people, and the death rate was also higher: 3.6 per 100,000 compared with 1.8 per 100,000. “The severity of Covid-19 among Black Americans was the predictable result of structural and societal realities, not differences in genetic predisposition.” "Many Black Americans who contracted the coronavirus experienced serious illness because of pre-existing conditions like obesity, hypertension and chronic kidney disease, which themselves were often the result of “differential access to high-quality care and health promoting resources,” the report says. Read full story (paywalled) Source: New York Times, 29 March 2022
  20. News Article
    Patient safety and nursing groups around the country are lamenting the guilty verdict in the trial of a former nurse in Tennessee, USA. The moment nurse RaDonda Vaught realised she had given a patient the wrong medication, she rushed to the doctors working to revive 75-year-old Charlene Murphey and told them what she had done. Within hours, she made a full report of her mistake to the Vanderbilt University Medical Center. Murphey died the next day, on 27 December 2017. On Friday, a jury found Vaught guilty of criminally negligent homicide and gross neglect. That verdict — and the fact that Vaught was charged at all — worries patient safety and nursing groups that have worked for years to move hospital culture away from cover-ups, blame and punishment, and toward the honest reporting of mistakes. The move to a “Just Culture" seeks to improve safety by analyzing human errors and making systemic changes to prevent their recurrence. And that can't happen if providers think they could go to prison, they say. “The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent,” the American Nurses Association said. “Health care delivery is highly complex. It is inevitable that mistakes will happen. ... It is completely unrealistic to think otherwise.” Read full story Source: The Independent, 31 March 2022
  21. News Article
    Doctors too often "ignore" women's pain, Sajid Javid said as he called for change in the wake of the Shrewsbury maternity scandal. Writing for The Telegraph, the Health Secretary said the wider NHS needed to do much more to listen to women, adding that too many are left in pain and ignored by clinicians. On Wednesday, the Ockenden report revealed that the deaths of 201 babies and nine mothers at Shrewsbury and Telford NHS Trust could have been avoided, citing a failure to listen to women. Mr Javid wrote: "This week we have seen the tragic reality of what can happen when women's voices are not listened to when it comes to their care. "Donna Ockenden's report into maternity failings at Shrewsbury and Telford Hospitals raises specific concerns for maternity services, but more widely we must address issues across the whole of the health and care system when it comes to listening to women's concerns and recognising their pain." In the joint piece with Maria Caulfield, the minister for women’s health, Mr Javid welcomed a "shift in the way we talk about women's health", with more open discussions about areas once seen as taboo. But the pair said more needed to be done – specifically to improve the treatment of endometriosis, an extremely painful gynaecological condition. "We must ensure all women feel confident in going to their GP when they experience symptoms of endometriosis and, when they do, that they are listened to," they said. Too many were "spending too long in pain waiting for a diagnosis, often feeling ignored by clinicians", they warned. Later this year the Government will publish a women's health strategy, which will examine issues including fertility, menopause, and prevention and treatment of diseases. Read full story (paywalled) Source: The Telegraph, 31 March 2022
  22. News Article
    Stroke and heart attack victims are now routinely waiting more than an hour for an ambulance, after a further fall in performance in recent weeks, and with hospital handover delays hitting a new high point, HSJ reveals. Figures for ambulance performance this week, seen by HSJ, showed average response times for category two calls at more than 70 minutes for successive days. 3,000 patients may have suffered “severe harm” from delays in February, ambulance chief executives say. Several well-placed sources in the sector said response times had deteriorated further this month, and that more than half of ambulance trusts were this week seeing average category two responses of longer than an hour. Some cited an average category two response last week of around 70 minutes, with the services under huge pressure from a combination of demand, long handover delays, and covid-related sickness. Category two calls include patients with suspected heart attacks and strokes, and the national target for reaching them is 18 minutes. The figures seen by HSJ for this week showed average response times for category one calls — the most serious, including cardiac arrests and other immediately life threatening emergencies — of more than 10 minutes on Wednesday, against a target of just 7 minutes. Monthly average performance for category one has never reached 10 minutes. Read full story (paywalled) Source: HSJ, 1 April 2022
  23. News Article
    Nearly 900 patients with type 1 diabetes in England are testing a potentially life-changing artificial pancreas. It can eliminate the need for finger prick tests and prevent life-threatening hypoglycaemic attacks, where blood sugar levels fall too low. The technology uses a sensor under the skin. It continually monitors the levels, and a pump automatically adjusts the amount of insulin required. Six-year-old Charlotte, from Lancashire, is one of more than 200 children using the hybrid closed loop system. Her mother, Ange Abbott, told us it has made a massive impact on the whole family. "Prior to having the loop, everything was manual," she said. "At night we'd have to set the alarm every two hours to do finger pricks and corrections of insulin in order to deal with the ups and downs of Charlotte's blood sugars." Prof Partha Kar, NHS national speciality adviser for diabetes, said: "Having machines monitor and deliver medication for diabetes patients sounds quite sci-fi like, but technology and machines are part and parcel of how we live our lives every day. "It is not very far away from the holy grail of a fully automated system, where people with type 1 diabetes can get on with their lives without worrying about glucose levels or medication." Read full story Source: BBC News, 1 April 2022 Further reading on the hub How safe are closed loop artificial pancreas systems?
  24. News Article
    A number of London GP practices are training their receptionists to do blood tests, Pulse has learned. Professor Sir Sam Everington, a GP and chair of Tower Hamlets CCG, told Pulse that ‘lots of practices’ in the area have taken the step, including his own. Training a receptionist to carry out blood tests – which can be done in just six weeks – provides much-needed support to pressured practices, he said. Dr Everington told Pulse: ‘A lot of our receptionists have signed up to be phlebotomists and they love it because actually, phlebotomy is not just about taking blood. "You get to know all the patients with long-term conditions and so our phlebotomists know all these patients." He added that reception teams are a ‘fertile recruitment ground’ for a phlebotomist. They can ‘manage even the most terrified patients’ and have ‘amazing’ clinical skills. Dr Everington suggested that training receptionists as phlebotomists can help build trust with patients who are suspicious about having to describe their symptoms for triage by reception staff. But he said that the extra role just ‘acknowledges’ that all members of practice staff are ‘part of the clinical team’. He told Pulse: "In our practice, we all train together. We have meetings together, the whole team, and it’s acknowledging in this modern world that actually every member of your staff is a clinician – part of the clinical team – because there are always things they will do or can do that will have an impact clinically." "There isn’t a hidden supply of GPs out there in the next few years. It takes 10 years to train GPs so actually help is going to come from a wider team base." Read full story Source: Pulse, 31 March 2022
  25. News Article
    Less than half of staff at scandal-hit Shrewsbury and Telford Hospital NHS Trust feel they can speak up about concerns, according to a staff survey, as a damning report warned serious problems persist in maternity care. Shrewsbury and Telford Hospital Trust is one of the worst-performing trusts on the latest national survey of staff for the NHS. It comes after Donna Ockenden, who chaired a review into maternity failures at the trust, said her “biggest concern” was that staff had been told not to share concerns with her inquiry. Ms Ockenden told The Independent her biggest concern was “that ordinary staff on the ground are telling me they were advised not to cooperate with the Ockenden review”. The NHS staff survey, published on Wednesday, showed just 49% of staff at the trust reported they would feel safe enough speaking up about concerns in 2021 – down from 53% in 2020. Meanwhile, just 34% of staff said they feel their concerns would be addressed if there were to speak up. The trust is one of the worst three hospital trusts in the country when it comes to rising care concerns, the figures show. Only United Lincolnshire Hospitals NHS Trust and Barking, Havering and Redbridge University Hospitals NHS Trust performed worse. Read full story Source: The Independent, 31 March 2022
×
×
  • Create New...