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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    More than 80% of GPs believe that patients are being put at risk when they come into their surgery for an appointment, a new survey shows. A poll of 1,395 GPs found only 13% said their practice was safe for patients all the time. Meanwhile, 85% expressed concerns about patient safety, with 2% saying patients were “rarely” safe, 22% saying they were safe “some of the time” and 61% saying they were safe “most of the time”. Asked if they thought the risk to patient safety was increasing in their surgery, 70% said it was. Family doctors identified lack of time with patients, workforce shortages, relentless workloads and heavy administrative burdens as the main reasons people receiving care could be exposed to risk. The survey, which was self-selecting, also found that: 91% said more GPs would help improve the state of general practices. 84% have had anxiety, stress or depression over the past year linked to their job. 31% know a colleague who was physically abused by a patient in the last year. 24% know of a member of general practice staff who has taken their own life due to work pressures. Read full story Source: The Guardian, 21 March 2022
  2. News Article
    A paediatrician who was at the centre of one of Northern Ireland's longest running public inquiries will appear before a professional misconduct panel. Dr Heather Steen is accused of several failings following the death of Claire Roberts at the Royal Belfast Hospital for Sick Children in October 1996. The nine-year-old's death was examined by the hyponatraemia inquiry, which lasted 14 years. It examined the role of several doctors. Among his findings, the inquiry's chairman Mr Justice O'Hara said there had been a "cover-up" to "avoid scrutiny." Monday's tribunal will inquire into allegations that, between 23 October 1996 and 4 May 2006, Dr Steen "knowingly and dishonestly carried out several actions to conceal the true circumstances" of the child's death. Also that the doctor provided inappropriate, incomplete and inaccurate information to the child's parents and GP regarding the treatment, diagnosis, clinical management and cause of her death. The tribunal website adds: "It is also alleged that Dr Steen inappropriately recommended a brain-only post-mortem for Patient A (Claire Roberts) when a full post-mortem was necessary. "In addition, it is alleged that Dr Steen failed to refer Patient A's death to the coroner, inappropriately completed the medical certificate of cause of death and inaccurately completed the autopsy request form for Patient A. "Furthermore, it is alleged that during a review of Patient A's notes, Dr Steen failed to consult with the necessary colleagues and medical teams and provided a statement and gave evidence to the coroner's inquest into Patient A's death which omitted key information." Read full story Source: BBC News, 21 March 2022
  3. News Article
    Infection control rules in hospitals are ‘now disproportionate to the risks’ posed by covid and should be relaxed, some of the NHS’s most senior leaders have warned. The government rules – such as not allowing covid-positive staff to work, and separating out services for covid, non-covid and covid-contact patients – make a big dent in hospital capacity and slows down services. Glen Burley, who is chief executive of three Midlands trusts and involved in national-level discussions on elective matters, told HSJ: “Pretty much every pathway has a covid and non-covid route, which slows down flow and staff productivity. “There is a growing argument that these rules are now disproportionate to the risks. With covid cases in the community also rising now, we may have to question again the relative risks of continuing to isolate staff.” NHS Confederation director of policy Layla McCay told HSJ: “Healthcare leaders are concerned the current [IPC] measures are having a serious knock-on effect on capacity and that the measures in their current form are reducing efficiency and capacity within healthcare settings. “We need more clarity on if and how current measures can be safely adjusted so [the NHS] can further increase bed capacity and patient throughput, as well as the ability to transport patients more quickly and efficiently.” But NHS Providers, which has previously said relaxing the IPC guidance would not enable a “rapid” increase in the NHS’ capacity to tackle the elective care backlog and could pose significant “risks”, remains more cautious. Read full story (paywalled) Source: HSJ, 21 March 2022
  4. Content Article
    World Patient Safety Day (WPSD) is observed globally on 17 September every year. The objectives of WPSD are to increase public awareness and engagement, enhance global understanding, and work towards global solidarity and action by all stakeholders to improve patient safety. The theme of WPSD 2021 was “Safe Maternal and Newborn Care” and all stakeholders were urged to “act now for safe and respectful childbirth!”. Maternal and child mortality is one of the major health issues of the current times. Every day we lose 810 women due to pregnancy-related complications, 6,700 newborns lose their lives, and there are 5,400 stillbirths globally. The tragedy is that most of these deaths are avoidable through the provision of safe care. The World Patients Alliance (WPA) conducted the largest WPSD campaign globally as over 800 events were organised all over the world. This newsletter presents highlights of these events. 
  5. Content Article
    People with COVID-19 often have symptoms in the long term (ie, long COVID), including fatigue, breathlessness, and neurocognitive difficulties. The disease mechanisms causing long COVID are unknown, and there are no evidence-based treatment options. Clinical guidelines focus on symptom management, and various treatment options are being evaluated. The scarcity of advice has often left people with long COVID feeling isolated and frustrated in their search for therapies. Research is needed to understand the self-management practices that are being used to manage long COVID symptoms; factors influencing their uptake; and the benefits, harms, and costs. There is also a need to assess the potential harmful effects of polypharmacy and drug–drug interactions in these individuals. The Therapies for Long COVID (TLC) Study (ISRCTN15674970) will begin to explore self-management practices through a survey of people with long COVID. This study aims to be a first step towards understanding this important and under-researched public health issue. 
  6. Content Article
    The Guidance for Human Factors Evaluations in the Procurement of Medical Devices, Equipment and Technology document provides comprehensive recommendations on how one may integrate human factors evaluations into procurement processes. While it is a relatively new aspect to consider in healthcare supply management, and may entail robust change management to implement, incorporating human factors evaluation in purchasing will enable best value and outcomes in health care.
  7. Content Article
    “Hi, I’m the doctor. First I need to apologise for how long you’ve been waiting.” An apology is now the default way I introduce myself to patients in the busy emergency department where I work, writes an emergency medicine consultant in an article for the Independent newspaper. An apology for the shortage of beds, an apology for the shortage of staff and most importantly for the person in front of him, an apology for how long they’ve waited, in pain and distress, to be seen.
  8. Content Article
    In this article published by Economics By Design, Colin Lewry and Jacque Mallender argue that, despite recent history, treating healthcare staff as a cost and not an asset needs to be reversed when developing workforce plans and approaches in 2022.
  9. Content Article
    Last month, Boris Johnson argued that the downward trends in Covid cases and hospitalisations meant that it was time to scrap restrictions. Now both are rising. But the government is ending testing and most surveillance studies. Sajid Javid, the health secretary, said that the rise was “to be expected” – though this foresight did not extend to having a plan to deal with the increase in infections. Instead, he dismissed the concern about the new Deltacron variant. The health secretary seemed nonchalant about the threat the virus now posed. Sajid Javid may be right that the country has weathered the worst of the pandemic, but Covid is not yet in retreat. It makes no sense to withdraw funding from a series of studies that allow the spread of the virus to be mapped in detail. Without the data, experts won’t be able to effectively monitor the disease. The country will be less effective in responding and adjusting to future waves of infection. Individuals will be less able to make informed choices about the risks involved. The clinically vulnerable face being cut off from everyday life. “It is like turning off the headlights at the first sign of dawn,” Stephen Reicher, a psychologist at the University of St Andrews, told the Guardian. “You can’t see what’s coming and you don’t know when it makes sense to turn them on again.”
  10. News Article
    US health officials are monitoring an unusual situation in the UK, where COVID-19 cases and hospitalisations are simultaneously climbing due to the BA.2 subvariant, CNN reports. COVID-19 cases were up 52% in the UK last week compared with the week prior, and hospitalisations were up 18%t over the same period, according to the UK Coronavirus Dashboard. The seemingly in-tandem ascent of cases and hospitalisations is unusual, given that increases in COVID-19 cases preceded increases in hospitalisations by about 10 days to two weeks in previous waves. "So we're obviously keenly interested in what's going on with that," Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, told CNN. Dr Fauci said in conversation with his U.K. counterparts, they attribute the rising cases and hospitalisations to three things, listed in order of contribution: the BA.2 variant, which is more transmissible than the original omicron; the opening of society, with people socializing indoors without masks; and waning immunity from vaccination or prior infection. Hospitalisations in the U.K. raise questions, given that BA.2 doesn't appear to cause more severe disease. "The issue with hospitalization is a little bit more puzzling, because although the hospitalizations are going up, it is very clear their use of ICU beds has not increased," Dr. Fauci said. "So are the numbers of hospitalizations a real reflection of COVID cases, or is there a difficulty deciphering between people coming into the hospital with COVID or because of COVID?" Read full story Source: Becker Hospital Review, 16 March 2022
  11. Content Article
    Mr David O’Regan, Director of the Faculty of Surgical Trainers, offers this new video series exploring topics that are pertinent to surgical training and trainers. He looks beyond the field of surgery and interviews internationally recognised professionals in their own fields. He also features conversations with a select group of esteemed surgeons who are recognised for their impact on effective training – both giving and receiving – has had on their career and their legacies. Role modelling, situation awareness and team playing are key to reading any training scenario and David will discuss with his guests how a variety of skills required across a huge range of industries can benefit discussions and offer best practice in Surgical Training.
  12. Event
    This conference focuses on patient involvement and partnership for patient safety including implementing the New National Framework for involving patients in patient safety, and developing the role of the Patient Safety Partner (PSP) in your organisation or service. The National Framework for involving patients in patient safety was released by NHS England in June 2021. This conference will enable you to: Network with colleagues who are working to involve patients in improving patient safety. Reflect on patient perspective. Understand how to implement the June 2021 National Framework for Involving Patients in Patient Safety. Improve the way you recruit, work with and support Patient Safety Partners. Develop your skills in embedding compassion and empathy into patient partnership. Understand how you can improve patient partnership and involvement after serious incidents. Identify key strategies for support patients, their families and carers to be directly involved in their own or their loved one’s safety. Learn from case studies demonstrating patient partnership for patients safety in action. Examine methods of involving patients to improve patient safety in high risk areas. 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 hub members receive a 20% discount. Email info@pslhub,org for discount code.
  13. Event
    Aimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process and safety. This conference will enable you to: Network with colleagues who are working to embed a human factors approach. Learn from outstanding practice in using human factors and ergonomics to improve patient safety and quality. Reflect on national developments and learning including the patient safety syllabus and new role of patient safety specialist. Understand the tools and methodology. Develop your skills in training and educating frontline staff in human factors. Understand how you can improve patient safety incident investigation by using a human factors approach. Learn from case studies demonstrating the practical application of human factors to improve patient care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/human-factors-in-healthcare or email kate@hc-uk.org.uk hub members can receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #HumanFactors
  14. Content Article
    The Competition and Markets Authority (CMA) has published an open letter calling for all hospitals to comply with the Private Healthcare Market Investigation Order. The Order entered into force on 1 October 2014 and requires the performance measures of private healthcare facilities, and the performance measures and fees of consultants providing privately-funded healthcare services to be published by the Private Healthcare Information Network (PHIN).The CMA has asked PHIN and its members to provide a detailed roadmap outlining how the Order will be complete by June 2026. Over the next few months there will be opportunities for all interested parties to contribute to this roadmap, including consultant representative groups, insurers and other stakeholders.
  15. News Article
    An inspection of a county's urgent and emergency services found delays were caused by a lack of empty beds and prolonged waiting times. The Care Quality Commission (CQC) inspected Gloucestershire emergency care services in November and December. The report found staff worked well in challenging circumstances but the CQC said pressures on workers across the system needed addressing. Dr Jeremy Welch said: "The system is being stretched and we need to adapt." CQC deputy chief inspector for hospitals, Nigel Acheson, said: "We found the system to be complicated. As a result, staff and patients weren't always able to understand which urgent and emergency care service was best suited to their needs. "This meant people sometimes attended the emergency department when they could have been treated more appropriately elsewhere." In addition the report touched on adult social care and the possibility of using empty care home beds when hospitals were struggling to cope. Dr Welch recognised "it's been a blinking tough time in care homes" over the pandemic and credited the relaxing of rules to allow visits but said there are other factors that would need to be considered. However he added: "We've got enough beds when we map across, it's just getting patients through the hospital and home because home is where they want to be." Read full story Source: BBC News, 17 March 2022
  16. News Article
    The carer who admitted the manslaughter of Adelaide woman Ann Marie Smith, who had cerebral palsy, has been jailed for at least five years and three months for her criminal neglect. Sentencing Rosa Maria Maione in the Supreme Court, Justice Anne Bampton said the 70-year-old was grossly negligent, with her care for Smith falling well short of the standard expected. “You did not mobilise her from the chair in which she was found. You did not toilet her properly and you did not clean her properly,” she told Maione on Friday. “You did not feed her a nutritional diet or monitor her intake. You knew you were not capable of properly supporting her and you did not seek assistance in providing for Ms Smith’s needs." “Despite the deterioration in Ms Smith’s health, you did not seek assistance from your supervisor or medical professionals until it was too late.” Justice Bampton said Maione had absolutely no insight into Smith’s physical condition leading up to her death. “Your incompetence, lack of training, lack of assertiveness and lack of supervision produced an environment where you failed to provide appropriate care,” she said. “Every person living with a disability, every person who requires support, every parent, carer and support worker of persons living with a disability, I have no doubt shudders with fear when they hear of the utter lack of care and human dignity afforded to Ms Smith in those last months of her life.” Read full story Source: The Guardian, 18 March 2022
  17. News Article
    Just 1 in 10 patients preferred face-to-face GP appointments during the Covid pandemic, with most requesting telephone consultations instead, according to research carried out on behalf of NHS England. The Improvement Analytics Unit (IAU) – a partnership between NHS England and think-tank the Health Foundation – looked at data from 146 England GP practices using the askmyGP online consultation system between March 2019 and September 2021, examining over 7.5 million patient-initiated consultation requests. During the pandemic, GPs suffered a backlash from the media, Government and NHS England over accusations that general practice was closed and GPs were not seeing patients face-to-face. GP leaders suggested that NHS England needed to take the research into account and allow practices to decide their own way of working. The research found that: Before the pandemic, 30% of patients requests specified a face-to-face consultation, dropping to less than 4% at the beginning of the pandemic. But by the end of the study period in September 2021, only 10% of patients requests were for face-to-face GP appointments. Telephone consultations were the most popular option, making up over half (55%) of patient requests in 2020/21. However, less than 1% of patients preferred a video consultation, according to the data. IAU head at the Health Foundation Arne Wolters said: ‘Our analysis shows that patients often choose remote over face-to-face consultations and that GP practices can mitigate the risk of digital exclusion via a blended approach.’ He said that ‘traditional routes to accessing and delivering care’ had been ‘offered alongside an online option and, in planning care, practices were able to take account of factors such as patients’ age, frequency of use, clinical needs and preferences’, at the studied practices." And he added: ‘With patient demand at an all-time high due to the care backlog Read full story Source: Pulse, 18 March 2022
  18. News Article
    The UK’s drug regulator has approved a combination of two monoclonal antibodies to prevent Covid-19 in people who are unlikely to mount an immune response from vaccination or for whom vaccination is not recommended. Evusheld, a combination of the two long acting antibodies tixagevimab and cilgavimab, is authorised for Covid-19 prevention by the Medicines and Healthcare products Regulatory Agency (MHRA). The government’s independent advisory body, the Commission on Human Medicines, endorsed the approval after independently reviewing the evidence. Almost 500 000 people in the UK are immunocompromised, including people with blood cancers, those taking immunosuppressive drugs after an organ transplant, or those with conditions such as multiple sclerosis and rheumatoid arthritis. The treatment could offer this group of patients, many of whom are still shielding, protection against Covid-19 and help them feel more confident about returning to a normal life. June Raine, MHRA chief executive, said, “While Covid-19 vaccines continue to be the first line of defence, we know that some people may not respond adequately to these vaccines and for a small number they may not be recommended. For these people, Evusheld could provide effective protection against Covid-19.” Penny Ward, an independent pharmaceutical physician and visiting professor in pharmaceutical medicine at King’s College London, said, “This treatment could be a good way to protect patients who are not able to respond normally to vaccination. Many of these people are continuing to shield while Covid is still circulating in the community and this agent could help them feel more confident to return to a more normal life.” Read full story Source: BMJ, 17 March 2022
  19. News Article
    Hundreds of England’s care homes could be closed and care rationed because the government has “seriously underestimated” the costs of a shake-up, experts are warning. Widespread closures would leave hundreds of thousands of elderly and vulnerable residents homeless. Those in the southeast, the east and the southwest would be hardest hit, according to a new study. Under a package of social care reforms announced in September, ministers are aiming to make care fees fairer between private and state fee payers. At the moment, residents who self-fund all their care pay up to 40% more on average than those eligible for state support, for whom their local authority arranges care, and care homes charge councils lower rates. Read full story Source: The Independent, 18 March 2022
  20. Content Article
    COVID-19 has meant activity in general practice has changed dramatically over the last 2 years. Practices have moved rapidly towards remote triage and care delivery to reduce risk of infection. Many have also delivered a large proportion of the COVID-19 vaccination programme as part of Primary Care Networks (PCNs), alongside their usual patient care. Understanding the total workload of general practice is vital for planning, research and supporting practices under pressure. However, the data we have on activity in general practice are limited, especially compared with hospital data. This has made it challenging to accurately track the ongoing impact of COVID-19 on general practice. This short analysis from The Health Foundation uses data from different sources, some publicly available and some not, to explore recent trends in general practice activity in England. We also present data on the general practice workforce, to help contextualise activity levels. It highlights what the data can tell us – and importantly, what it can’t.
  21. Content Article
    Research on maternity care often focuses on factors that prevent good communication and collaboration and rarely includes important stakeholders – parents – as co-researchers. To understand how professionals and parents in Dutch maternity care accomplish constructive communication and collaboration, Korstjens et al. examined their interactions in the clinic, looking for “good practice”.
  22. Content Article
    Within the last two decades, it has been commonly agreed that patient safety and error management in healthcare organizations can best be attained by adopting a systems approach via re-engineering efforts and the introduction of industrial safety technologies and methodologies. This strategy has not delivered the expected result. Based on John Dewey’s pragmatism, in this study Kirstine Z. Pedersen and Jessica Mesman propose another vocabulary for understanding, inquiring into and learning from safety situations in healthcare. Drawing especially on Dewey’s understanding of transaction as the inseparability between human and environment, they develop an analytical approach to patient safety understood as a transactional accomplishment thoroughly dependent on the quality of situated and shared habits and collaborative practices in healthcare. They further illustrate methodologically how a transactional attitude can be situationally practised through video-reflexive ethnography, a method that allows for inquiry into mundane safety practices by letting interprofessional teams see, reflect upon and possibly modify their shared practices and safety habits.
  23. News Article
    A large mental health trust has highlighted a lack of additional funding for the sector, in contrast to the £8bn earmarked for acute providers to tackle elective waiting lists. Tees, Esk and Wear Valleys Foundation Trust expects demand for its services to be 20% higher than pre-covid levels, but says uncertainties around funding could “impede” progress and “wider service sustainability”. In an interview with HSJ last week, TEWV’s chief executive Brent Kilmurray said: “Quite often, we are facing the challenge of trying to find beds and meet demand. What we’ve seen is an increase in occupancy and an increase in length of stay. And we are relating that to an increase in acuity. “We really welcome the investment that goes into the long-term plans on the specialist services that are coming through. [But] what we want to do with our work is give greater transparency to the backlogs that have developed and some of the additional pressures. Asked about the trust’s actions to address multiple concerns around safety and quality, Mr Kilmurray said staffing had improved in forensics, although the vacancy rate is still higher than the trust average, and that a leadership development programme is aiming to improve the culture of the organisation. He said he hopes the CQC “would see significant improvement” when they are inspected again. He added that “a lot has changed” since the high-profile deaths of two teenagers under the care of the trust, which are subject to an ongoing inquiry He said: “We will be able to build on the legacy of those young women in terms of the learning that we want to embed within the organisation.” Read full story (paywalled) Source: HSJ, 16 December 2022
  24. News Article
    A Wisconsin dentist was found guilty of healthcare fraud and other charges after he intentionally damaged his patients’ teeth to boost profits, raking in millions from his scheme. Scott Charmoli, 61, was convicted of five counts of healthcare fraud and two counts of making false claims about his clients’ treatment last Thursday, according to the Milwaukee Journal Sentinel. With his sentencing scheduled for June, Charmoli faces up to 10 years for each healthcare fraud charge and a maximum of five years for each of the two other charges. Prosecutors say that Charmoli had routinely drilled or broken his clients’ teeth on purpose, charging them for additional treatment services to fix the damage he had just done. As a result, Charmoli’s profits ballooned, with the dentist going from making $1.4m and installing 434 crowns in 2014 to $2.5m in 2015, installing over 1,000 crowns, reported the Washington Post. According to prosecutors, in 2015, Charmoli began pressuring his clients into getting unnecessary crowns, a dental procedure where a tooth-shaped cap is placed on a damaged tooth. Charmoli would drill or break his client’s teeth and send X-rays of the intentional damage to insurance as “before” photos to justify the crown procedures. One client, Todd Tedeschi, testified that Charmoli pressured him into getting two crowns in one appointment, despite Tedeschi believing that his teeth were fine. “It seemed excessive, but I didn’t know any better,” said Tedeschi. “He was the professional. I just trusted him.” Some of the patients that Charmoli badgered into unnecessary procedures were also vulnerable, said prosecutors. Read full story Source: The Guardian, 16 March 2022
  25. Content Article
    This month an inquiry will deliver its verdict on the failures of maternity care at the Shrewsbury and Telford Hospital NHS Trust, the largest maternity scandal in NHS history, involving 1,862 families. The result of this inquiry will highlight how we may need to reconfigure maternity services to ensure the highest standard of care.  But what does good really look like? Is there really a way to be a safe maternity unit?  At last year's Patient Safety Congress, one of the sessions aimed to answer these questions. The panel discussed behaviours and practices that constitute safe care in hospital-based maternity units, and how organisations can take practical steps to make these features a reality. Click on the video below to watch the full session.
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