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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Extrapolation from a recent poll suggests that about 16 million adults in the UK found it difficult to access healthcare services during the pandemic, and of these, one in eight opted to access private healthcare. This could create the conditions for a two tier system, whereby those with the means to pay have access to healthcare more quickly than those who don’t. This would jeopardise the high levels of support the NHS has enjoyed since its establishment and have serious implications for equity in access to healthcare services. But this is unlikely because of limited capacity in the private sector writes Michael Anderson and Elias Mossialos in this BMJ editorial.
  2. Event
    Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. WHO Patient Safety Flagship has initiated a series of monthly webinars on the topic of “WHO Global Patient Safety Challenge: Medication Without Harm”,. The main objective of the webinar series is support implementation of this WHO Global Patient Safety Challenge: Medication Without Harm at the country level. Considering the huge burden of medication-related harm, Medication Safety has also been selected as the theme for World Patient Safety Day 2022. Medication errors cause patient harm and death at a very high rate. It happens not only inside the health care facilities but also anywhere patients take medication. How to capture the medication safety incidents and learn from them have been a critical issue for patient safety. A country-wide/organsation-wide reporting and learning system that captures and analyses medication errors is proven to help estimate the magnitude of harm, identify system gaps, and develop measures to prevent reoccurrences. Furthermore, a nationwide pharmacovigilance system helps capture adverse drug reactions and informs regulators, healthcare professionals, and the public about safety concerns regarding pharmaceutical products. This webinar will discuss the medication error reporting and learning, as well as the pharmacovigilance systems which are widely used globally. Register
  3. Content Article
    Published 10 times a year by the Association for Perioperative Practice, the IPP covers a variety of topics relevant for perioperative practitioners. Ranging from news and information, special focus pieces, industry interviews and profiles of company leaders in an easy-to-read format.
  4. News Article
    Banning home abortions could increase risks to women and waste NHS resources, leading doctors have warned. The “pills by post” system is set to be dismantled in England by September, having been introduced as a temporary measure at the start of the pandemic. However, the plans, disclosed by The Telegraph last month, have sparked outrage from medical organisations and women’s groups. The decision by ministers to return to pre-pandemic abortion systems in England has sparked fierce debate and could be subject to a vote in Parliament on Wednesday. Writing for The Telegraph, the leaders of the Academy of Medical Royal Colleges, the British Medical Association and the Royal College of Obstetricians and Gynaecologists have urged ministers to reconsider their intentions. They said that the current system has meant terminations take place earlier in the pregnancy, reducing the risk of complications, and that the most vulnerable women, including domestic abuse victims, are able to get help. Baroness Sugg of Coldharbour, a former operations chief to David Cameron, said that the UK should “stand strongly against the rollback of women’s rights”. She has also tabled an amendment to the Health and Care Bill seeking to maintain the current system in England. Read full story (paywalled) Source: The Telegraph, 15 March 2022
  5. News Article
    Some care homes have "no choice" but to allow workers who have Covid to deliver care, a public health official said. According to Public Health England cases are rising the fastest in Somerset. As a result, care homes in the county are struggling to safely staff their services and schools are seeing a rise in staff sickness. Somerset Council said ensuring vulnerable residents received care was "lower risk" than them being infected. Health officials advised care workers to continue working only if they wore PPE and felt well enough. Council public health consultant Alison Bell said: "In some cases, we have no choice but to have people who are testing positive delivering care to people in Somerset. "That risk is actually less than that person not receiving care." She said the Omicron variant was more transmissible and people were getting re-infected with it, some within a matter of weeks. Read full story Source: BBC News, 16 March 2022
  6. News Article
    Women and NHS staff have warned that mothers are being “forgotten” after giving birth, with a staff crisis only making matters worse. Kate, a 32-year-old from Leeds, says she has been left in “excruciating” pain for nine years after horrifying postnatal care. Other women have told The Independent stories of care ranging from “disjointed” to “disastrous”. It comes as midwives warn there are “horrendous” shortages in community services, which have prevented women from accessing adequate antenatal and postnatal care. Mary Ross-Davie, the Royal College of Midwives’ director for professional midwifery, said that with each Covid wave midwifery staffing has been hit worse than the last. To provide safe care during labour, antenatal and postnatal care, teams are sent into wards putting “huge pressure on care”. She said this could mean clinicians end up “missing things”, such as women struggling emotionally after birth. The warnings over poor antenatal and postnatal care come after experts at the University of Oxford said in November there were “stark” gaps in postnatal care, despite the highest number of deaths being recorded in the postnatal period. Dr Sunita Sharma, lead consultant for postnatal care at Chelsea and Westminster Trust, said that when NHS maternity inpatient staffing overall is in crisis “often the first place staff are moved from is the postnatal ward, which is clinically very appropriate, but it can come at a cost of putting more pressure on postnatal care for other mothers”. Dr Sharma said postnatal teams were doing their best to improve services but need national drivers and funding to sustain improvement. Read full story Source: The Independent, 16 March 2022
  7. News Article
    The purpose of Care Quality Commission (CQC) ratings has been a hotly contested question since the creation of the four category classifications in the last decade. The original idea was to give the public a sense of how good their local hospital was, as well as providing commissioners, system managers and government with an idea of whether the local, regional or national health services they had responsibility for were getting better or worse. The practicality of the first aim was always questionable given the public’s inability and unwillingness, in most cases, to take their custom elsewhere. The second ran into the lack of desire and/or courage on behalf of most commissioners to challenge their local provider, but it did seem to have traction at the top of the shop. Jeremy Hunt, told HSJ, once they had been dished out across the sector, that their CQC classification now mattered much more then whether or not it had achieved foundation status or not. Another function, whether intended or not, was that by splashing “inadequate” and unsafe care on the front pages, in the wake of the Francis report, CQC ratings fuelled a drive to put more staff on the wards (forcing the Treasury to pay for the consequent agency bills and deficits, and curtailing Simon Stevens’ transformation funds). Whatever your take on their purpose, however, they only make sense if they accurately reflect the state of the service. And the latest data suggests that may not be the case. Read full story (paywalled) Source: HSJ, 17 March 2022
  8. News Article
    More than 1,300 patients a year are having NHS funding for their palliative care withdrawn after living longer than expected, BBC analysis shows. Terminally ill or rapidly-declining patients are given fast-track support, allowing them to live outside hospital. From 2018 to 2021, a total of 9,037 people had this funding reviewed in England and Wales, with 47% of them losing all support. A further 15% of patients had their continuing healthcare support replaced with the more limited NHS-funded nursing care. Sandra Hanson was referred to the fast-track pathway of the NHS continuing healthcare scheme in mid-2020, after her needs were judged by a clinician to be "end of life". She was diagnosed with end-stage dementia, and had been in hospital eight times in the previous year following multiple falls and bouts of pneumonia. The funding covered the costs of a nursing home, where she suffered fewer falls. But in March 2021, this funding was reviewed by her local Clinical Commissioning Group (CCG). These assessments, usually undertaken by a multi-disciplinary team including health and social care professionals, consider the severity of a person's needs in areas such as mobility, cognition and behaviour. Sandra's daughter, Charlotte Gurney, said the family was represented by a social worker they had not previously met, and describes the meeting as "traumatic" as she tried to explain her mum's needs. "We just felt not listened to... we were treated as if we were trying to swindle the system. Sandra's support was withdrawn, and she had to be moved to a new nursing home, financed by her husband Malcolm. Shortly afterwards, she broke her wrist following a fall and injured her face. The family believe had the review correctly identified Sandra's needs and risks, this could have been avoided. Read full story Source: BBC News, 17 March 2022
  9. Event
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    Cardiovascular disease (CVD) is the leading cause of death in the UK, yet is largely preventable. It is the single biggest area where the NHS can save lives over the next decade, and as such, is a core priority in the NHS Long Term Plan. With the onset of the COVID-19 pandemic, came an acceleration in adoption of technology as a tool within the NHS - both in clinic and in community - to enhance patient outcomes and professional pathways. These available technologies have a significant role to play, both broadly in alignment with the NHS LTP and also more specifically in the quest to close the atrial fibrillation detection gap. This webinar will highlight the technologies available to the NHS for ambulatory monitoring of CVD and also showcase recent NICE recommendation of the first and only personal ECG to achieve such status. Speaking on this topic will be Trudie Lobban, CEO and Founder of the Arrhythmia Alliance, and Dr Matt Reed, Consultant in Emergency Medicine, Edinburgh. Register
  10. Event
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    As part of its mission to promote good governance, the Good Governance Institute (GGI) host facilitated, weekly virtual meetings to give NHS non-executive directors an opportunity to share their concerns, challenges and ideas as we rethink the future of health and social care. The goal is to collectively think about the role NEDs play as part of the controlling mind of their organisations, to discuss immediate safeguarding issues and to ensure we all learn from this experience to assure better outcomes for citizens in the future. Patient safety has been moving up the Board agenda in recent years, yet it remains the case that avoidable deaths still equate to the loss of a aeroplane each and every week. In this session Helen Hughes will discuss how Boards can change their culture and practice to integrate patient safety into their agendas. • What role can standards play in the patient safety agenda? • How can the patient perspective be made integral to patient safety? • What can we learn from other sectors about patient safety? • What are the checklist questions all Boards should be thinking about in relation to patient safety? Register
  11. Content Article
    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. KePSIE is one of the worlds largest trials on improving patient safety, testing at scale complementary approaches to protect patients and prevent disease outbreaks. KePSIE provides validated tools to measure patient safety and assess facility performance in resource-poor primary care settings across multiple domains; development of an inspection checklist in collaboration with the country and large-scale pilot of inspections using a professional cadre and globally relevant empirical evidence on the effectiveness of government inspections and consumer empowerment to ensure patient safety.
  12. Content Article
    Learn more about Long Covid and common symptoms like fatigue, cognitive dysfunction, post-exertional symptoms exacerbation, and orthostatic intolerance. Produced by Long COVID Physio. Long COVID Physio is an international peer support, education and advocacy, patient-led association of physiotherapists living with Long COVID and allies working internationally across advocacy, policy, guideline development and research.
  13. Event
    This National Virtual Summit focuses on the New National NHS Complaint Standards that were published in March 2021 and are due to be introduced across the NHS in 2022. Through national updates, practical case studies including NHS Complaints Standards early adopters sites, and in depth expert sessions the conference aims to improve the effectiveness of complaints handling within your service, and ensure that complaints are welcomed and lead to change and improvements in patient care. The conference will also reflect on managing complaints regarding Covid-19 – understanding the standards of care by which the NHS should be judged in a pandemic and in particular responding to complaints regarding delayed treatment due to the pandemic. This conference will enable you to: Network with colleagues who are working to improve complaints handling. Update your knowledge on the March 2021 NHS Complaint Standards and how it will change complaints handling for the better. Understand how to manage complaints regarding Covid-19. Reflect on the perspective of a complainant who has been through the system to understand what person centred really means in practice. Learn how to bring kindness and compassion into complaints management, investigation, responses and learning. Understand what PHSO and the CQC look for in a good complaint response. Self assess your service against the NHS Complaint Standards. Improve the way complaints and investigations involving serious incidents are handled. Develop your skills in complex complaints handling including disputes, vexatious complainants and complaints across organisations. Understand how you can improve frontline resolution of complaints in real time. Develop your skills in de-escalation and conflict and dispute resolution. Support staff through the complaints process including inquests. Identify key strategies for ensuring change occurs as a result of complaints. Ensure you are up to date with the latest legal issues including ensuring adherence to the duty of candour. Self assess, reflect and expand your skills in complaints handling. 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
  14. News Article
    An ‘outstanding’ London trust has come under fire for asking staff to communicate ‘only in English’ when around other people. A document published under the ‘trust values’ section of Homerton University Hospital Foundation Trust’s website, says: “I will only communicate in English in the presence of others.” The document has been widely shared on social media in the last 24 hours, with many criticising the trust for its wording. The document itself is dated 2014, but was reposted by the trust in 2019, and remained on its website as of midday today. NHS England’s director of equality – medical workforce, Partha Kar, who is also NHSE’s diabetes lead, questioned the document on Twitter. He also said: “I am not aware of any NHS England ‘diktat’ suggesting we must all only speak in English to uphold NHS values.” It follows a separate notice being posted on Twitter yesterday signed simply by “Matron”, by a doctor who claimed her friend saw it at her “hospital placement”. It seemingly threatened staff with “disciplinary action” if they spoke any other language other than English. It reads: “English is the only language to be spoken in the ward area – this includes the kitchen. Disciplinary action will be taken against staff who do not comply, including agency and bank.” The documents have prompted a backlash on Twitter, with many criticising them and raising concerns about racism and inclusivity of staff. NHSE’s chief nursing officer, Ruth May, has publicly queried where the document is from. Read full story (paywalled) Source: HSJ, 16 March 2022
  15. Content Article
    Eurocontrol’s HindSight magazine is a magazine on human and organisational factors in operations, in air traffic management and beyond. This issue has articles from front-line staff and specialists in safety, human factors, and human and organisational performance, in aviation and elsewhere. The articles cover all aspects of everyday work, including routine work, unwanted events, and excellence. The authors discuss a variety of ways to learn from everyday work, including observation, discussion, surveys, reflection, and data analysis. There are articles on specific topics to help learn from others’ experience, including from other sectors in ‘views from elsewhere’
  16. News Article
    This week is Patient Safety Awareness Week (13-19 March) and is an annual recognition event intended to encourage everyone to learn more about healthcare safety. During this week, the US Institute for Healthcare Improvement (IHI) seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce. Patient Safety Awareness Week serves as a dedicated time and platform for growing awareness about patient safety and recognising the work already being done. Find out more here.
  17. News Article
    Patients waiting for surgery and cancer care in England will face long delays for years to come, MPs have warned in a new report that is highly critical of both ministers and NHS bosses. The already-record 6.1 million-strong waiting list for vital treatment will keep growing and officials are “too optimistic” that plans to tackle it will succeed, the public accounts committee (PAC) said in a report on Wednesday. “For the next few years it is likely that waiting time performance for cancer and elective care will remain poor and the waiting list for elective care will continue to grow,” it said. The committee of MPs, which monitors spending across Whitehall, acknowledges Covid-19’s role in contributing to the ballooning backlog and lengthening waiting times. But it singled out years of inaction by the Department of Health and Social Care (DHSC) for particular blame. Patients waiting for surgery and cancer care in England will face long delays for years to come, MPs have warned in a new report that is highly critical of both ministers and NHS bosses. The already-record 6.1 million-strong waiting list for vital treatment will keep growing and officials are “too optimistic” that plans to tackle it will succeed, the public accounts committee (PAC) said in a report on Wednesday. “For the next few years it is likely that waiting time performance for cancer and elective care will remain poor and the waiting list for elective care will continue to grow,” it said. The committee of MPs, which monitors spending across Whitehall, acknowledges Covid-19’s role in contributing to the ballooning backlog and lengthening waiting times. But it singled out years of inaction by the Department of Health and Social Care (DHSC) for particular blame. Read full story Source: The Guardian, 16 March 2022
  18. News Article
    Admissions of covid positive patients to English hospitals are once again rising steadily across England. The seven day total of new confirmed covid cases in hospitals on 12 March (the latest data available) stood at 9,642. This is 46% higher than the seven day total of 6,612 recorded on 25 February, the day before the current rise began. Asked on Radio 4’s Today programme yesterday about the rise in Covid infections, health and social care secretary Sajid Javid said there was “nothing in the [covid] data that gives us any cause for concern”. The Covid admissions figures used include patients who are already covid-positive when admitted, are diagnosed on admission, or are diagnosed while in hospital, so in some cases have caught Covid while in hospital. Read full story (paywalled) Source: HSJ, 15 May 2022
  19. News Article
    The government has overseen years of decline in cancer care and non-urgent hospital services in England, MPs say. The House of Commons Public Accounts Committee said services had started deteriorating long before the pandemic. It pointed out key targets had not been met since 2016 and the pandemic had just exacerbated the problems. But ministers said they were investing extra money and creating more capacity to treat patients, to address the backlog that had now developed. More than six million people are currently on a hospital waiting list - one in nine of the population - the highest figure on record. This includes people waiting for operations such as knee and hip replacements. Meanwhile, just two-thirds of urgent cancer patients start treatment within the target time of 62 days. And the number of referrals for cancer care has dropped by between 240,000 and 740,000 since the pandemic started. The MPs said people would face serious health consequences because of delays in cancer treatment, with some dying earlier. The government is also accused of failing to recognise staffing the health service remains its biggest problem. The MPs said the workforce was crippled by shortages and exhausted by two years of the pandemic. Read full story Source: BBC News, 15 March 2022
  20. News Article
    Pregnant women should be asked how much alcohol they are drinking and the answer recorded in their medical notes, new "priority advice" for the NHS says. The advice, from the National Institute for Health and Care Excellence (NICE), is designed to help spot problem drinking that can harm babies. Infants with foetal alcohol spectrum disorder (FASD) can be left with lifelong problems. The safest approach during pregnancy is to abstain from alcohol completely. The more someone drinks while pregnant, the higher the chance of FASD - and there is no proven "safe" level of alcohol. But the risk of harming the baby is "likely to be low if you have drunk only small amounts of alcohol before you knew you were pregnant or during pregnancy", the Department of Health says. An earlier draft of the recommendations for NHS staff in England and Wales suggested transferring data on a woman's alcohol intake to her child's medical notes - but this has now been dropped, following concern women who needed help might hide their drinking. The Royal College of Midwives spokeswoman Lia Brigante said: "As there is no known safe level of alcohol consumption during pregnancy, the RCM believes it is appropriate and important to advise women that the safest approach is to avoid drinking alcohol during pregnancy and advocates for this. "We are pleased to see that the recommendation to record alcohol consumption and to then transfer this to a child's record has been reconsidered. "This had the potential to disrupt or prevent the development of a trusting relationship between a woman and her midwife." Read full story Source: BBC News, 16 March 2022
  21. News Article
    People who suffer from severe Covid-19 symptoms are more likely to have long-term mental health problems, a new study suggests. Higher rates of depression and anxiety have been found in people who were “bedridden” with Covid-19 for more than seven days last year, according to a study published in the Lancet. Scientists, drawing on data from 247,249 people across the UK, Denmark, Estonia, Iceland, Norway and Sweden, found that people with coronavirus who were not admitted to hospital were more likely to experience symptoms of depression up to 16 months after diagnosis, compared to those never infected. However, over 16 months, patients who were bedridden for seven days or more were between 50 and 60% more likely to experience higher levels of depression and anxiety compared to people never infected during the study period, the researchers found. Overall, people diagnosed with Covid-19 had a higher prevalence of depression and poorer sleep quality compared with individuals who were never diagnosed – 20% of those in the former group experienced symptoms of depression, versus 11% in the latter group. Researchers suggested patients who spent longer in bed or had higher depression or anxiety rates could be suffering from ill health due to a combination of worrying about long-term health effects and Covid symptoms persisting. Patients with severe Covid often experience inflammation, which has previously been linked to chronic mental illness, particularly depression. Read full story Source: The Independent, 15 March 2022
  22. News Article
    Lateral flow tests could cost care home visitors £73 a month, a leading UK charity has said, as it renewed calls to keep the devices free in such settings. The government has previously announced that free testing for the general public will end from 1 April, and that this will include care home visitors. However, charities have warned the shift away from free tests could place a heavy financial burden on those visiting care homes, where testing is still advised. James White, the head of public affairs and campaigns at the Alzheimer’s Society, said the proposed charge on lateral flow tests for visitors to care homes was a cruel tax on care. “Over the past two years, we’ve consistently heard many tragic stories from families struggling to visit their loved ones in care homes. For many people with dementia, this isolation has led to a significant deterioration in their condition and mental health,” he said. “With infection rates rising once again, the government must provide free lateral flow tests for all visitors to care homes so that families are not put in an agonising position where they are forced to ration visits, leaving people with dementia once again isolated and alone.” Caroline Abrahams, Age UK’s charity director, said: “No one should have to pay out of their own pocket for tests in circumstances where the expert advice is clear that testing remains an important safeguard against Covid,” she said. “If care home visitors are going to continue to be asked to keep testing to protect their loved ones, it would be completely unacceptable to expect them to pay.” Read full story Source: The Guardian, 15 March 2022 Further reading Visiting restrictions and the impact on patients and their families: a relative's perspective
  23. Content Article
    Matthews et al. investigated inequalities in stillbirth rates by ethnicity to facilitate development of initiatives to target those at highest risk. They found that stillbirth rates declined in the UK, but substantial excess risk of stillbirth persists among babies of black and Asian ethnicities. The combined disadvantage for black, Pakistani and Bangladeshi ethnicities who are more likely to live in most deprived areas is associated with considerably higher rates. Key causes of death were congenital anomalies and placental causes. Improved strategies for investigation of stillbirth causes are needed to reduce unexplained deaths so that interventions can be targeted to reduce stillbirths.
  24. Content Article
    Roger Kline, Research Fellow at Middlesex University Business School, comments on the Government “Action Plan” on racism.
  25. Event
    Sensemaking, according to Karl Weick, is the process through which the complex and unpredictable world is given order, within which people can orient themselves, find purpose, and take effective action. Organisations unravel when sensemaking collapses, when they no longer supply meaning, and when they cling to interpretations that no longer work. As we enter the third year of a global COVID-19 pandemic, when nearly every aspect of our care and caring has faced disruption, how do we make sense of and take action to prevent the unraveling of organisations and sustainably reverse setbacks in patient and workforce safety? Join IHI’s annual Patient Safety Awareness Week webinar on March 16, 2022 from 11:00 AM to 11:50 AM ET with speakers Don Berwick, MD, MPP, and Jessica Berwick, MD, MPH, for a conversation on sensemaking during times of uncertainty, complexity, and chaos. This session will provide insights and perspective to foster sensemaking and action to reinforce patient and workforce safety in your organisation. Register
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