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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    A doctor's bid to be voluntarily removed from the medical register on health grounds has been rejected. It means Dr Heather Steen, who is accused of failings following the death of Claire Roberts in 1996, will still face a fitness to practice tribunal. The tribunal would have been halted if she had been removed from the register, as she would no longer have been a doctor. Claire Roberts died at the Royal Belfast Hospital for Sick Children, where Dr Steen worked, in October 1996. The nine-year-old's death was examined as part of the hyponatraemia inquiry. Her father Alan said his family welcomed the decision to refuse the paediatrician's application. He said the tribunal hearing was "in the public interest" and should proceed "to maintain public confidence in the medical profession, the regulatory process and to ensure that professional standards are upheld". Read full story Source: BBC News, 28 March 2022
  2. News Article
    The government must stop treating women “like children” and permanently allow at home early medical abortions, MPs and health professionals have said. Abortion rules changed after Covid hit the UK in March 2020, with the government allowing abortion pills to be sent via post to be taken at home after a phone consultation. The new system - referred to as “telemedicine” - was due to run out on 25 March but the government declared a six-month extension for at home early medical abortions earlier in the month. MPs are now set to vote on whether to make telemedicine abortion services permanent on Wednesday. Clare Murphy, chief executive of the British Pregnancy Advisory Service (BPAS), told The Independent: “We welcome the vote. MPs have the opportunity to prevent the recriminalisation of women who use Stella Creasy, a Labour MP and campaigner for abortion rights, is one of many MPs calling for telemedicine abortion services to be made permanent. “Despite the best attempts to scare, telemedicine has been shown to be safe, secure and preferable for many patients for a variety of reasons - it’s time to trust women and ensure they can make the right choices for themselves when it comes to their own medical care”, she said. Read full story Source: The Independent, 29 March 2022
  3. News Article
    Scottish Liberal Democrat leader and health spokesperson Alex Cole-Hamilton MSP today said the SNP/Green Government has “yet again let down long Covid sufferers” as it is revealed that not a single penny of the £10 million announced by ministers last September has been spent. On 9 September 2021, the Scottish Government announced the £10 million Long Covid Support Fund. Now a parliamentary question from Alex Cole-Hamilton and a freedom of information request have confirmed that the money remains entirely unspent. Alex Cole-Hamilton commented: “The latest official statistics showed a record are a record 119,000 long Covid sufferers in Scotland. The SNP/Green Government has let down every single one of them by failing to spend any of the £10 million it announced last September. “Time and again I have pressed Nicola Sturgeon for answers on the absence of long Covid clinics, pressed for automatic referrals and urged the rollout of in-home support for sufferers. Now we’ve learned that none of the money announced more than six months ago has been spent. “Long Covid sufferers need new hope. Scottish Liberal Democrats are determined to see the rollout of proper care. Read full story Source: Scottish Liberal Democrats, 27 March 2022
  4. Content Article
    Sweden was well equipped to prevent the pandemic of COVID-19 from becoming serious. Over 280 years of collaboration between political bodies, authorities, and the scientific community had yielded many successes in preventive medicine. Sweden’s population is literate and has a high level of trust in authorities and those in power. During 2020, however, Sweden had ten times higher COVID-19 death rates compared with neighbouring Norway. In this report, Nele Brusselaers et al. try to understand why, using a narrative approach to evaluate the Swedish COVID-19 policy and the role of scientific evidence and integrity. We argue that that scientific methodology was not followed by the major figures in the acting authorities—or the responsible politicians—with alternative narratives being considered as valid, resulting in arbitrary policy decisions.
  5. Content Article
    A woman who experiences pain during caesarean section under neuraxial anaesthesia is at risk of adverse psychological sequelae. Litigation arising from pain during caesarean section under neuraxial anaesthesia has replaced accidental awareness under general anaesthesia as the most common successful medicolegal claim against obstetric anaesthetists. Generic guidelines on caesarean section exist, but they do not provide specific recommendations for this area of anaesthetic practice. This guidance aims to offer pragmatic advice to support anaesthetists in caring for women during caesarean section. It emphasises the importance of non-technical skills, offers advice on best practice and aims to encourage standardisation. The guidance results from a collaborative effort by anaesthetists, psychologists and patients and has been developed to support clinicians and promote standardisation of practice in this area.
  6. News Article
    The chief executive of one of England’s most prestigious private hospitals has lost her employment tribunal claim that she was dismissed for whistle blowing over patient safety issues. Aida Yousefi ran the Portland Hospital in central London from January 2017 until her dismissal in December 2019 on two counts of gross misconduct. She was also in charge of The Harley Street Clinic and a specialist cancer centre. Ms Yousefi’s argument that she was removed after raising concerns about the patient safety was rejected by central London employment tribunal in a judgment published last week. The judge instead ruled that while other senior staff had raised patient safety concerns over cost-cutting, there was no evidence that Ms Yousefi had done so. In their judgment the tribunal panel said: “In oral evidence the claimant further accepted that, as CQC-registered manager, if patient safety concerns were not being dealt with she should have raised it with CQC. She did not do so at any point during her employment.” Staffing concerns were raised by The Harley Street Centre chief nursing officer Claire Champion and others. However, the tribunal heard evidence that doing so could be frowned upon by senior management at HCA International. The tribunal was shown an email from then vice president of financial operations at THSC and the Portland Enda O’Meara saying “Frankly – we are starting to piss some very senior people off in appearing that we can’t [make savings]. We can’t always cite patient safety. Because the response will always be other facilities are doing it”. Another email from Mr O’Meara said: “Please don’t cite ’patient safety’ unless you truly believe it to be the case. This term is particularly sensitive and nothing winds them up more”. Read full story (paywalled) Source: HSJ, 28 March 2022
  7. Content Article
    Between 2006 and 2009, WHO elaborated and issued the concept of ‘My Five Moments for Hand Hygiene’ in healthcare in collaboration with the pioneering infection prevention and control (IPC) research group at the University of Geneva. The primary objective of this approach is to facilitate behavioural change and prioritise hand hygiene action at the exact times needed to prevent the transmission of pathogens and avoid harm to patients and health workers during care delivery. Importantly, the Five Moments approach overcomes some relevant barriers to hand hygiene practices identified before its launch, such as long lists for hand hygiene action without any consideration of the dynamics of patient, health worker and environmental interactions The Five Moments approach is being constantly tailored to meet the challenges of care locations outside the traditional hospital setting, as well as across all countries and resource levels. The main thrust of the approach remains targeted at patient and health worker safety at the point of care where the risk of acquiring infection can be at its highest. Further work to help meet the Five Moments objectives through its adaptation and adoption worldwide is to be welcomed. WHO committed to further action and research on lessons learnt from field implementation, as well as the active dissemination of available tools to support countries to further understand and accept this proven approach.
  8. News Article
    The Royal College of Obstetricians and Gynaecologists (RCOG) has called for the immediate suspension of charging for NHS maternity care for migrant women because members say this government policy is harming the health of pregnant women and their babies. It is the first time the health professionals’ body has issued a position statement on this issue. The charity Maternity Action and the Royal College of Midwives have long expressed concern about the impact of NHS charging on this group of women. Charging forms a key plank of the Home Office’s hostile environment for migrants. The government says the charging policy is in place to deter health tourism but medics treating migrant pregnant women say there is little evidence that previously free NHS maternity care for all attracted health tourists. According to the 2019 MBRRACE-UK confidential inquiry into maternal deaths, three women were found to have died between 2015 and 2017 who may have been reluctant to access maternity care due to fears about charging and impact on their immigration status. Dr Brenda Kelly, an NHS consultant obstetrician working in Oxford, treats many pregnant migrant women. She is calling for the barriers to them accessing maternity care to be removed urgently. She described the case of one migrant woman who arrived in A&E shortly before delivering a stillborn baby. The woman had been fearful of coming forward for antenatal care although she was suffering from multiple, pregnancy-related health problems. “I hope I never have to hear cries like that woman’s cries ever again,” said Kelly. “The way to safeguard these women is to build up trust. If they are landed with a bill of several thousand pounds they will disengage. They are not health tourists, they are desperate. The commitment to maternal health equity means ending charges for maternity care. The time for action is now.” Read full story Source: The Guardian, 27 March 2022
  9. News Article
    RaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide on Friday after a three-day trial in Nashville, Tenn., that gripped nurses across the country. Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions, according to sentencing guidelines provided by the Nashville district attorney's office. Vaught is scheduled to be sentenced 13, and her sentences are likely to run concurrently, said the district attorney's spokesperson, Steve Hayslip. Vaught was acquitted of reckless homicide. Criminally negligent homicide was a lesser charge included under reckless homicide. Vaught's trial has been closely watched by nurses and medical professionals across the U.S., many of whom worry it could set a precedent of criminalising medical mistakes. Medical errors are generally handled by professional licensing boards or civil courts, and criminal prosecutions like Vaught's case are exceedingly rare. Read full story Source: OPB, 26 March 2022 See also: As a nurse in the US faces prison for a deadly error, her colleagues worry: Could I be next?
  10. Event
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    With general practice in crisis due to workforce shortages, an increasingly complex workload, rising public expectations, and further pressures caused by the Covid-19 pandemic, The King's Fund are providing the time and space for you to reflect, think differently, share and learn. Join peers and experts from The King’s Fund to explore: what the future of general practice looks like how the experience for patients and staff can be improved how to ensure those actions are building blocks towards the future. This event is for GPs, commissioners, nurses, practice managers, allied health professionals, Additional Roles Reimbursement Scheme (ARRS)-funded roles, and other professionals working in multidisciplinary general practice teams and those responsible for general practice at place or neighbourhood level. Register
  11. News Article
    An investigation has been launched after a woman died during childbirth at a hospital's maternity unit. It was the third death of a mother in just over three years at Basildon University Hospital in Essex, in addition to a newborn baby's death. The trust that runs the hospital said it could not comment on the case while it was under investigation. Basildon University Hospital is part of Mid and South Essex NHS Foundation Trust, which also runs Southend and Broomfield hospitals. The latest fatality follows the death of 36-year-old Gabriela Pintilie in February 2019. Ms Pintilie died after losing six litres of blood giving birth to her second child at the unit. In separate incidents, a mother died and another woman had a stillborn baby at the unit in March 2019, while the trust was being inspected by the Care Quality Commission (CQC) following Ms Pintilie's death. The unit at Basildon had its rating upgraded from "inadequate" to "requires improvement" in December by the CQC. The hospital also apologised for the death of newborn Frederick Terry after he suffered a brain haemorrhage during a failed forceps delivery in November 2019. Read full story Source: BBC News, 27 March 2022
  12. News Article
    Burnout is not a strong enough term to describe the severe mental distress nurses and other NHS staff are experiencing, says a doctor who has led efforts to improve care for health professionals. Medical director of the NHS Practitioner Health service Dame Clare Gerada told MPs radical action was needed to improve the mental well-being of NHS staff. She said nurses and other healthcare staff should be entitled to one hour of paid reflective time per month to be written into NHS employees’ contracts, alongside mentoring, careers advice and leadership training built in throughout people’s careers. Dr Gerada was among senior clinicians who gave evidence this week to the Health and Social Care Committee, which is looking at issues around recruitment and retention of staff. She told the committee the term ‘burnout’ simply did not cover the level of stress and mental anguish experienced by NHS workers. ‘Burnout is too gentle a term for the mental distress that is going on amongst our workforce,’ she said. High suicide rates among nurses and doctors, high levels of bullying and staff being sacked because they have long-COVID are all signs the health service is failing to look after its employees, she said. ‘The symptoms we have got are the symptoms of an organisation that is unable to care for its workforce in the way that it should be caring,’ she said. Read full story Source: Nursing Standard, 25 March 2022
  13. News Article
    When Debbie Greenaway was told by doctors that she should try to deliver her twin babies naturally, she was nervous. But the doctor was adamant, she recalls. “He said: ‘We’ve got the lowest caesarean rates in the country and we are proud of it and we plan to keep it that way'." For Greenaway, labour was seemingly endless. She was given repeated doses of syntocinon, a drug used to bring on contractions. By the second day, the midwife was worried for one of the babies, whom the couple had named John. “She was getting really concerned that they couldn’t find John’s heartbeat.” Her husband remembers “the midwife shaking her head”. “She said a number of times that we should be having a caesarean.” By the time doctors finally decided to perform an emergency C-section, it was too late. Starved of oxygen, baby John had suffered a catastrophic brain injury. When he was delivered at 3am, he had no pulse. Efforts to resuscitate him failed. Their son’s death was part of what is now recognised as the largest maternity scandal in NHS history. The five-year investigation will reveal that the experiences of 1,500 families at Shrewsbury and Telford Hospital Trust between 2000 and 2019 were examined. At least 12 mothers died while giving birth, and some families lost more than one child in separate incidents, the report is expected to show. The expert midwife Donna Ockenden and a team of more than 90 midwives and doctors will deliver a damning verdict on the Shrewsbury trust, its culture and leadership — and failure to learn from mistakes or listen to families. At its heart is how a toxic obsession with “normal birth” — fuelled by targets and pressure from the NHS to reduce caesarean rates — became so pervasive that life-or-death decisions on the maternity ward became dangerously distorted for nearly two decades. Read full story (paywalled) Source: The Times, 26 March 2022
  14. News Article
    More than 1,500 patient deaths are to be investigated in the largest-ever independent inquiry into “unacceptable” mental health care. A probe into the deaths of patients who were cared for by NHS mental health services across Essex has revealed its investigation will cover deaths from 2000 to 2020. All 1,500 people died while they were a patient on a mental health ward in Essex, or within three months of being discharged from one. In 2001, following an investigation into 25 deaths, police criticised the trust for “clear and basic” failings but did not pursue a corporate manslaughter prosecution. And in 2021, the Health and Safety Executive fined the trust £1.5m due to failures linked to the deaths of 11 patients. The regulator said the trust did not manage the risks of ligature points for a period of more than 10 years. In January 2021, following pressures, former patient safety minister Nadine Dorries commissioned former NHS England mental health director Dr Geraldine Strathdee to chair an independent inquiry. While it is not known yet how many of the 1,500 deaths were caused by neglect, Dr Strathdee said evidence had so far shown some “unacceptable” and “dispassionate” care. Melanie Leahy, who has campaigned for change within Essex mental health services since her son died in 2012, has been leading the call for it to become a public inquiry on behalf of the families. Her son, Matthew Leahy, died as an inpatient at the Linden Centre, following multiple failings in his care. A 2018 parliamentary health service ombudsman report on his death, and that of another young man called Richard Wade, identified “systemic” failings on behalf of the trust. These included the failure to manage his risk level, to look after his physical health and to take action when he reported being raped in the unit. Read full story Source: The Independent, 28 March 2022
  15. News Article
    Amazon, eBay and Wish have stopped stocking some monitors that let people keep track of their blood oxygen levels after an investigation found they were not fit to be sold. The online marketplaces removed a number of pulse oxygen testing devices known as oximeters from sale after being alerted to flaws identified by the consumer organisation Which? Pulse oximeters have boomed in popularity as a result of Covid, with millions of people keeping one at home so they can quickly assess if their blood oxygen level has fallen worryingly low – a condition known as “silent hypoxia” – which is a common side-effect of the disease. Some of the devices were not legally fit to be sold in the UK, did not carry the CE quality Kitemark or wrongly claimed that they had been approved by the NHS. The Department of Health and Social Care (DHSC) said it would look into the unauthorised use of the health service’s iconic blue and white branding on the devices. It made clear that “the NHS does not approve or endorse any medical devices, including oximeters”. “The department strictly controls the NHS identity and takes unauthorised use or adaptation of the NHS logo and the letters ‘NHS’ very seriously”, a DHSC spokesperson said. Which? said that 11 of the cheap pulse oximeters it bought from those websites failed to comply with UK and European Union law when it examined them closely. “It is very concerning that our investigation found these medical devices for sale without the required safety markings or brazenly claiming to be approved by the NHS, and the biggest online marketplaces were not picking up on these red flags”, said Natalie Hitchens, the consumer group’s head of home products and services. Read full story Source: The Guardian, 26 March 2022
  16. News Article
    A whistleblower who worked at a hospital trust where hundreds of babies died or were left brain-damaged says there was "a climate of fear" among staff who tried to report concerns. Bernie Bentick was a consultant obstetrician at the Shrewsbury and Telford NHS Trust for almost 30 years. "In Shrewsbury and Telford there was a climate of fear where staff felt unable to speak up because of risk of victimisation," Mr Bentick said. "Clearly, when a baby or a mother dies, it's extremely traumatic for everybody concerned. "Sadly, the mechanisms for trying to prevent recurrence weren't sufficient for a number of factors. "Resources and the institutionalised bullying and blame culture was a large part of that." More than 1,800 cases of potentially avoidable harm have been reviewed by the inquiry. Most occurred between 2000 and 2019. Mr Bentick worked at the Trust until 2020. He said from 2009 onwards, he was raising concerns with managers. "I believe there were significant issues which promoted risk because of principally understaffing and the culture," he said. He also accuses hospital bosses of prioritising activity - the number of patients seen and procedures performed - over patient safety. "I believe that the senior management were mostly concerned with activity rather than safety - and until safety is on a par with clinical activity, I don’t see how the situation is going to be resolved," he said. Read full story Source: Sky News, 27 March 2022
  17. Content Article
    Gender bias in healthcare is a well-recognised issue. From diagnosis to drug development and treatment, the modern healthcare system has been shown to advantage men over women. Responsibly designed artificial intelligence (AI) and machine learning algorithms have the potential to overcome gender bias in medicine. However, if machine learning methods are implemented without careful thought and consideration they can lead to the perpetuation and even accentuation of existing biases. How can we develop technology in a way that prevents rather than perpetuates bias? This blog from Babylon highlights 4 key principles that can help.
  18. Content Article
    Sadly, we live in a world where racism, misogyny, ableism and other forms of discrimination and prejudice exist. As an organisation that is rooted in and serves our community, we are not exempt from such discriminatory beliefs and behaviours, writes Solent Trust’s Anna Rowen in this HSJ article.
  19. Content Article
    Civility Saves Lives have created a number of infographic each with a key message of civility. A selection are shown below and more can be found through the link at the bottom of the page.
  20. Content Article
    Earlier this month The BMJ and the Nuffield Trust hosted a roundtable discussion about the workforce crisis. It took in a wide range of perspectives, but the message was clear: the workforce crisis is urgent, it is affecting staff morale and wellbeing, it is damaging patient care, and it requires immediate action. It’s not just a UK problem; it’s a global crisis, but some countries are better at recognising the relation between staff morale and wellbeing, better patient care and economic growth. Simply put, your economy won’t grow if your population is unhealthy; your population won’t be healthy if your health professionals are demoralised and unwell.
  21. Content Article
    People affected by health conditions bring insights and wisdom to transform healthcare – ‘jewels from the caves of suffering'. Yet traditional patient and public engagement relies on (child–parent) feedback or (adolescent–parent) ‘representative' approaches that fail to value this expertise and buffers patients' influence. This editorial from David Gilbert outlines the emergence of ‘patient leadership' and work in the Sussex Musculoskeletal Partnership, its patient director (the first such role in the National Health Service) and a group of patient/carer partners, who are becoming equal partners in decision-making helping to reframe problems, generate insight, shift dynamics and change practice within improvement and governance work.
  22. Content Article
    Plans to establish integrated care systems (ICSs) as statutory bodies in the health and care bill foreshadow further changes to the organisation of the NHS. Unlike previous reorganisations, the changes expected to occur in 2022 have developed from within the NHS rather than being imposed by the government. Not only this, but leaders in the NHS have also played a major part in shaping the nature of these changes in partnership with the centre.  This paper from the NHS Confederation focuses on the changes needed to create the conditions in which ICSs can improve outcomes for patients and the public and outlines a series of simple rules to guide those leading the reform programme. The ideas put forward are intended to provide a basis for debate with healthcare leaders and others in England about next steps. The paper starts from the premise that a key role of leaders is to harness the intrinsic motivation of health and care staff and public health teams to perform to the best of their abilities. The distinctive contribution of ICSs is to work with partners in making use of all available assets and leading improvements in patient care and outcomes that require actions across the organisations and services that make up the health and care system. Staff must be fully engaged in this work as it is through their actions that patients and the public will experience improvements
  23. Event
    This one day masterclass will focus on improving Patient Safety through enhancing psychological safety and safety culture. It looks at effective ways to encourage health professionals to routinely embed high-quality clinical evidence into their everyday work. We will explore the characteristics of relatively successful behaviour change interventions. All Clinical Staff and Team Leads should attend. Key learning objectives: psychological safety safety culture behaviour human factors how to improve safety reporting. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/improving-psychological-safety-patient-safety or email nicki@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code
  24. Event
    This conference, chaired by Simon Hammond Director of Claims Management NHS Resolution will update clinicians and managers on Clinical Negligence with a particular focus on current issues and the Covid-19 pandemic and the impact on clinical negligence claims. Featuring leading legal experts, and experienced clinicians the event will provide an update on current claims the conference will discuss why patients litigate, and responding to claims including claims regarding Covid-19. There will be an extended masterclass on trends in clinical negligence claims and responding to claims followed by an extended focus on maternity claims, and also claims related to medication error. The conference will close with a case study on the advantages of bringing together complaints, claims and patients safety investigation, and practical experiences of Coronavirus complaints at claims at an NHS Trust – including understanding the standard of care on which services should be judged, and a final session on supporting clinicians when a claim is made against them. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/clinical-negligence or email nicki@hc-uk.org.uk We are delighted to offer 3 free places for hub members. Email info@pslhub.org for the discount code. Follow on Twitter @HCUK_Clare #clinicalnegligence
  25. News Article
    NHS England must find hundreds of millions of pounds in last-minute savings to pay for ongoing covid staff tests, it has been revealed NHSE chief financial officer Julian Kelly told a meeting of NHS England’s board: “We have been asked to see if we can cut core NHS funding - at the moment that is probably to the tune of £500m.” Mr Kelly said achieving this would likely involve “slowing down” some transformation programmes and ambitions in the Long Term Plan. He added that rising inflation could add an extra £1bn in financial pressure, telling the board “we’re going to have to look at what that means for our ability to deliver NHS goals in the round.” It was reported in February that Health Secretary Sajid Javid and Chancellor Rishi Sunak were at loggerheads over whether the Department of Health and Social Care (DHSC) should receive additional funding for covid testing on top of the health service’s spending envelope. The row is said to have led to a delay in plans to scrap all remaining virus-related restrictions. The DHSC reduced its ask for extra cash down from £5bn to an eventual £1.8bn but even this lower sum was rejected by the Treasury, according to reports. This means continuing staff testing will have to paid for out of the existing NHS budget. Read full story (paywalled) Source: HSJ, 24 March 2022
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