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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    This report highlights the importance of embracing a culture of change in the design and delivery of women’s health to achieve national systems and local services fit to meet the expectations and needs of the 21st century woman. It describes the many failings of health services across the world whose default position is to treat women as second-class citizens and place unnecessary barriers to the delivery of high-quality accessible care.  The report sets out recommendations, founded on common sense and rooted in the belief that women should be in control of their own bodies.
  2. Content Article
    Recovering services from the covid crisis is the big task for NHS leaders for the foreseeable future. HSJ's Recovery Watch newsletter tracks prospects and progress. This week HSJ bureau chief and performance lead James Illman discusses virtual wards and why staffing pressures are ‘likely to be under-estimated’ and are a patient safety risk.
  3. News Article
    Nearly one in five items of personal protective equipment (PPE) the government bought during the pandemic are not fit for purpose and cannot be used by the NHS, it has been revealed – including 1.2 billion items that cannot be used at all. As of December, almost 7 billion items of personal protective equipment bought for frontline services – 19.1% of the 36.4 billion items bought since February 2020 – had been marked “do not supply” to the NHS by the Department of Health and Social Care. The number is more than three times the figure quoted last September, when health minister Lord Bethell admitted 1.9 billion items worth £2.8bn were in the “do not supply” category – 6.2% of the PPE bought up to that point. The not-fit-for-purpose stock includes 1.2 billion units of PPE that cannot be used in any setting. This "wastage" – which accounts for 3.3% of pandemic PPE – includes around 800m aprons that DHSC is now looking to recycle, permanent secretary Sir Chris Wormald said in a letter to the Public Accounts Committee. The revelation comes as a consultation opens on the terms of reference for the public inquiry into the government's response to Covid. The inquiry will look at pandemic preparedness and the healthcare response, among other things. Read full story Source: Civil Service World, 11 March 2022
  4. News Article
    The only NHS gender identity service for children in England and Wales is under unsustainable pressure as the demand for the service outstrips capacity, a review has found. The interim report of the Cass Review, commissioned by NHS England in 2020, recommends that a network of regional hubs be created to provide care and support to young people with gender incongruence or dysphoria, arguing their care is “everyone’s business”. Led by the paediatrician Hilary Cass, the interim report explains that the significant rise in referrals to the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS foundation trust in London has resulted in overwhelmed staff and waiting lists of up to two years that leave young people “at considerable risk” of distress and deteriorating mental health. Last spring, the Care Quality Commission demanded monthly updates on numbers on waiting lists and actions to reduce them in a highly critical report on GIDS. Differing views and lack of open discussion about the nature of gender incongruence in childhood and adolescence – and whether transition is always the best option – means that patients can experience a “clinician lottery”, says the new review, which carried out extensive interviews with professionals and those with lived experience. It notes that the clinical approach used by GIDS “has not been subjected to some of the usual control measures” typically applied with new treatments. Another significant issue raised with the review team was that of “diagnostic overshadowing”, whereby once a young person is identified as having gender-related distress, other complex needs – such as neurodiversity or a mental health problem that would normally be managed by local services – can be overlooked. Read full story Source: The Guardian, 10 March 2022
  5. Content Article
    At present there is a single specialist service providing gender identity services for children and young people – the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust. In recent years GIDS has experienced a significant increase in referrals which has contributed to long waiting lists and growing concern about how the NHS should most appropriately assess, diagnose and care for this population of children and young people. The Cass Review has submitted an interim report to NHS England, which sets out their work to date, what has been learnt so far and the approach going forward. The report does not set out final recommendations at this stage.
  6. News Article
    A leading figure in the World Health Organisation Foundation has criticised the UK’s move to dismantle its Covid testing programme as the disease surges in other parts of the world. Mr Anil Soni, chief executive of the WHO Foundation, said in an interview with The Independent that maintaining surveillance over Covid-19 was “incredibly important” and the “dismantling of the testing infrastructure here strikes me as very worrying.” The WHO Foundation chief warned people were “looking the other way” from counties where there is low vaccine coverage to maintain the hope that Covid is over. He warned low vaccine coverage is a “petri dish” for future variants to breed and that the acute phase of the pandemic could not be over until this is addressed. When asked about the UK’s plans to end its NHS Test and Trace programme Mr Soni said: “I’m very concerned about it. “What we’ve seen is, it’s incredibly important to maintain surveillance, and countries in southern Africa should be applauded for detecting Omicron as quickly as they did. Those surveillance systems need to be in place around the world. “We also want to make sure that testing is widely available so that people, when they become infectious, can be aware of their status and keep others safe. For testing not to be available and for us to be moving too quickly to normalcy creates risk.” Mr Soni said the world’s position with Covid was “precarious” and highlighted the surge being seen in Hong Kong, where “health centres are at the verge of collapse, because of how many people are sick”. Read full story Source: The Independent, 10 March 2022
  7. News Article
    A midwife found guilty of misconduct over the death of a baby six years ago is to be struck off. Claire Roberts was investigated by the Nursing and Midwifery Council (NMC) for failures in the care she gave to Pippa Griffiths - who died a day after being born at home in Myddle, Shropshire. An independent disciplinary panel described the midwife as "a danger to patients and colleagues". Ms Roberts and fellow midwife Joanna Young failed to realise the "urgency" of medical attention needed, following the birth, the panel said. They had failed to carry out a triage assessment, after Pippa's mother called staff for help because she was worried about her daughter's condition. The panel concluded Ms Roberts's fitness to practise was impaired. Inaccurate record-keeping by Ms Roberts represented "serious dishonesty", panel chair David Evans said, adding she had carried it out "in order to protect herself from disciplinary action". Her failures had represented a "significant departure from standards expected by a registered midwife," he added. Her colleague Ms Young, whose case was also heard by the panel, faced strong criticism on Wednesday, but was told she would face no sanction after the hearing concluded she had shown remorse and undergone extra training since 2016. Kayleigh Griffiths said she and her husband welcomed the findings and sanctions. "We're really relieved that one of the midwives has been struck off and actually we're also relieved to find that the other midwife has learnt and feels significant remorse for the event that took place," she said. "We realise people do make mistakes and I think how you deal with those mistakes is really important. "All we do ask is that learning was made from those and I think in one of the instances it did occur and in the other it didn't - so I think the right outcome has been found." Read full story Source: BBC News, 10 March 2022
  8. News Article
    The draft terms of reference for the UK public inquiry into the government's handling of the Covid-19 pandemic have been published. The inquiry, due to start in the spring, will play a key role in "learning lessons" from the pandemic and for the future, it said. The terms of reference were published after a consultation with inquiry chairwoman and former High Court judge Baroness Hallett, and with ministers in the devolved nations. The Scottish government has already published the terms of reference for its own Covid-19 inquiry, to be led by Judge Lady Poole. The UK-wide inquiry proposes examining a broad range of issues including: the UK's preparedness for the pandemic the use of lockdowns and other 'non-pharmaceutical' interventions such as social distancing and the use of face coverings the management of the pandemic in hospitals and care homes the procurement and provision of equipment like personal protective equipment and ventilators support for businesses and jobs, including the furlough scheme, as well as benefits and sick pay. The inquiry aims to produce "a factual, narrative account" covering decision-making at all levels of government and the response of the health and care sector as well as identifying the "lessons to be learned". Becky Kummer, spokesperson for Covid-19 Bereaved Families for Justice, said the publication was a "huge step forward" and the organisation looked forward to contributing to the consultation on the terms. Chris Hopson, chief executive of NHS Providers, which represents hospital trusts, said there was much the NHS did well during the pandemic but: "It is right the inquiry looks at areas where there were major challenges - such as infection prevention and control, access to PPE, testing, and robust epidemiological modelling." Read full story Source: BBC News, 11 March 2022
  9. News Article
    The two-week wait cancer target should be scrapped and replaced with a different measure, as part of an overhaul of cancer standards, NHS England has said. After piloting a new measure which aims to see 75% of patients given the all-clear or a diagnosis within 28 days of referral, NHS England has recommended .The new “faster diagnosis target” would replace the current ‘two-week wait’ target, which is for 93% to have seen a specialist within two weeks, but not necessarily had a diagnosis. This proposal, and other changes to the way cancer waiting time targets are organised, will be consulted on until 6 April. The nine current cancer targets were created in 2000. The current headline measure along with the two-week wait — a two-month wait from urgent GP referral to first treatment — has not been hit since December 2015. The document containing the proposals said the current two-week standard saw some patients given an appointment at which no test was taken, purely to hit the target. For some suspected cancers, “many trusts… offer outpatient appointments to ensure they hit the target”, without improving diagnosis. The move to scrap the two-week wait was welcomed – with significant caveats — by Cancer Research UK Cancer Research UK chief executive Michelle Mitchell said: “The new Faster Diagnosis Standard is a more meaningful target than the current two-week wait that will hopefully improve early diagnosis. If all trusts met the 75 per cent target, it would be an improvement to where we are now. However, in the long-term to improve cancer survival, we’d like to see a 95 per cent target originally proposed in the 2015 cancer strategy in Sajid Javid’s upcoming 10-year plan for cancer. “We recognise the target was set lower because of a shortage of cancer specialists, critical to diagnosing cancer across the NHS. The government must provide the extra investment they have promised to grow the NHS workforce. Every moment of delay risks more people waiting for diagnosis and treatment.” Read full story (paywalled) Source: HSJ, 10 March 2022
  10. Content Article
    The introduction of remote triage and assessment early in the pandemic raised questions about patient safety. Wieringa et al. sought to capture patients and clinicians’ experiences of the management of suspected acute COVID-19 and generate wider lessons to inform safer care. Lessons from the pandemic suggest three key strategies are needed to prevent avoidable deaths and inequalities in the next crisis: (1) strengthen system resilience (including improved resourcing and staffing; support of new tools and processes; and recognising primary care’s role as the ‘risk sink’ of the healthcare system); (2) develop evidence-based triage and scoring systems; and (3) address social vulnerability.
  11. Content Article
    Through her work on a range of different elements of the Midlands leadership learning offer, Emma Coller has had great success in facilitating the development of the leadership skills and behaviours needed for positive change. Here she shares her insights on the appreciative inquiry process and how it works.
  12. Content Article
    Fewer than 1% of UK general practice consultations occur by video. This study by Trisha Greenhalgh and colleagues aims to explain why video consultations are not more widely used in general practice.
  13. Content Article
    This is the independent public inquiry to examine the UK’s preparedness and response to the Covid-19 pandemic, and to learn lessons for the future. The Inquiry has been established under the Inquiries Act 2005. This means that the Chair will have the power to compel the production of documents and call witnesses to give evidence on oath. The Chair has been appointed and will set out her vision for the Inquiry’s work in the coming months. The Inquiry has received the draft Terms of Reference from the Cabinet Office, and will open a public consultation tomorrow, Friday 11 March. The consultation will remain open for four weeks, and will be available online. See the UK COVID-19 Inquiry: draft terms of reference.
  14. Content Article
    How is the UK handling long Covid, one of the biggest health issues to emerge from the pandemic? A panel of experts brought together by The Independent discussed this and the overall message was that the UK’s response has been lacking. Chaired by Health Correspondent Rebecca Thomas and Science Correspondent Samuel Lovett, the panel included Dr Elaine Maxwell, Professor Amitava Banerjee and Professor Brendan Delaney. The session explores the UK’s response in depth from research approaches to provision for patients. Watch back a video of the full event.
  15. Content Article
    Medication errors harm patients and cost the NHS money – but with the right approach they can be significantly reduced. An HSJ article with Patrick Wilkinson and Nick Rodger from BD.
  16. News Article
    Antipsychotics have been frequently and increasingly prescribed for extended periods to people with recorded personality disorder but no history of severe mental illness, a study looking at UK general practice data has found. Researchers from University College London looked at 46 210 people who had had personality disorder recorded in their GP record between January 2000 and 31 December 2016. Of these, 15 562 (34%) had been prescribed antipsychotics. The study, published in BMJ Open, also found that 36 875 people with a record of personality disorder had no record of severe mental illness. An urgent review of clinical practice is warranted, including the effectiveness of such prescribing and the need to monitor for adverse effects, including metabolic complications. Read full story (paywalled) Source: BMJ, 10 March 2022
  17. News Article
    Delays in being able to get contraception and abortions can wreck women’s lives. It’s time women ignored the stigma and started complaining more loudly, writes Nell Frizzell in the Guardian. "When a friend recently told me that there was a 10-week waiting list to have a copper coil fitted, my shock turned quickly into anger. Ten weeks is a hell of a long time to wait for adequate, hormone-free, affordable contraception. We are experiencing a quiet crisis in contraceptive care in this country. According to a report by the Advisory Group on Contraception: “Going into lockdown, services had faced years of budget cuts by the government, leading to an 18% decrease in real-terms contraception spend since 2015.” The same report points out that there has also been a huge reduction in sites commissioned to deliver contraception (26% of local authorities cut sites in 2018-2019), meaning people are having to travel further to get the medical help they need, simply not to have an unplanned, unwanted, unaffordable or unsafe pregnancy. Unfortunately, the stigma still attached to contraception and reproductive health means people are less willing to complain publicly about the huge waiting times, the travel costs and the difficulty they face in accessing contraception and abortion. Subtly and overtly, we are told that this is our lot and we must bear it. Read full story Source: The Guardian, 9 March 2022 "
  18. News Article
    Urgent action is required to tackle hospital waiting times on both sides of the Irish border, according to the Economic and Social Research Institute (ESRI). A report into the primary healthcare systems of Ireland and Northern Ireland found that both jurisdictions are experiencing similar problems. These include workforce shortages and increasing expenditure. On hospital waiting times the problem is worse in Northern Ireland. The proportion of people on the waiting list in Northern Ireland for more than one year increased from 20% to 60%. In the Republic of Ireland, during the same period between 2017 and 2021, the figure increased from 12% to 20%. A key distinction between the healthcare systems is the absence of a universal healthcare system in Ireland, write the authors. That means in Northern Ireland, all residents are entitled to a wide range of free health care services, while in Ireland, the majority pay to see their GP and for other services. But despite this key difference, both systems are currently facing similar challenges, including shortages in key areas of the workforce and long waits for a range of healthcare services. Cross-border collaboration in healthcare across the island is an interesting but contentious issue. At present, according to the ESRI report, that work is relatively limited. It points to a 2011 report which identified the potential benefits to be gained from increased co-operation in healthcare including collaboration in cystic fibrosis, ear, nose and throat surgery, paediatric cardiac surgery and acute mental health services. However, this 2022 report concludes that despite some notable exceptions such as the Congenital Heart Disease Network and the North West Cancer Centre at Altnagelvin Hospital in Londonderry, "collaboration has been relatively limited". Read full story Source: BBC News, 10 March 2022
  19. News Article
    The charity SignHealth has been awarded a national contract with NHS England to supply the mental health service Talking Therapies in British Sign Language. The new specialist service will help to support deaf people who are experiencing anxiety, depression and other mental health issues. This marks the first time NHS England have granted a national contract to a deaf specialist service and will hope to bridge the gap and tackle the health inequalities recognised after a recent freedom of information (FOI) request found that around 100 NHS trusts do not comply with accessible information standards (AIS). Prior to the contract, deaf people experiencing mental health related issues would have to rely on funding from their Clinical Commissioning Group (CCG) to approve additional communication assistance on an individual basis. Waiting for approval of the funding for British Sign Language (BSL) therapy services meant that many deaf patients were having to wait considerably longer than their able hearing counterparts. Many CCGs do not grant additional funding and would not offer these kinds of services to deaf people, often resulting in ‘postcode lottery’. Dr Sarah Powell, Clinical Lead at SignHealth, said: "Deaf people are twice as likely to experience mental health challenges such as depression and anxiety compared to hearing people. This is a serious and sometimes life-threatening health inequality. Therapy delivered in sign language has been proven to have higher recovery rates and we are delighted that this contract removes the funding barrier so that more Deaf people are able to access life-changing treatment." Read full story Source: NHE, 9 March 2022
  20. News Article
    NHS England is trying to force a prestigious cancer trust to publicly apologise to a group of whistleblowers, after being ‘shocked’ by the way it responded to a review into their concerns. As HSJ reported in January, an external review into The Christie Foundation Trust supported multiple concerns which had been raised by staff about a major research project with pharma giant Roche. The review had also noted how 20 current and former employees, some of whom were “long-standing, loyal, senior staff”, had described bullying behaviours and felt they had suffered detriment because they spoke out. In response to the review, trust chair Christine Outram and chief executive Roger Spencer issued a bullish report listing numerous “inaccuracies” and characterised the concerns as being limited to a “small number of staff who are dissatisfied or aggrieved”. It did not thank the staff for raising the issues, nor apologise for the experiences they had. However, HSJ has now learned that NHSE is trying to ensure the trust issues a public apology. At a meeting with some of the whistleblowers on 11 February, David Levy, medical director for NHSE North West, said he was “shocked” and “frankly a bit angry” at the trust’s response, saying it reflected badly on the organisation, HSJ understands. Read full story (paywalled) Source: HSJ, 9 March 2022
  21. Content Article
    The Health Foundation will be carrying out an independent review of health and health inequalities in Scotland to provide a detailed and thorough analysis of the health trends and wider factors that have influenced people’s health in Scotland over the last two decades.  The study comes amid ongoing concern around widespread and persistent health inequalities in Scotland, which are likely to have further widened during the pandemic.  Sign up to stay in touch about health inequalities in Scotland: An independent review, and the Health Foundation's ongoing work and relevant events, 
  22. Content Article
    People like being treated well. A civil approach to relationships in the healthcare workplace – any workplace – has merit, but there are many questions to explore. While most doctors interact with others in a civil manner most of the time, anyone can experience lapses occasionally. When the many dimensions of civility are considered more closely, it appears that there is much that can be learned about the causes of incivility and the strategies that can be adopted to foster civil behaviour, even at times of risk. Physician Health Programme offers a series of articles below as Five Fundamentals of Civility for Physicians.
  23. Event
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    This conference will focus on why it remains so difficult to improve patient safety and learn from harm Despite huge efforts on the part of healthcare professionals to improve patient safety within the NHS, significant barriers remain. Prominent researchers have argued that it is difficult to ascertain whether patients are any safer, even after the many patient safety campaigns that have been run in the UK and internationally. This year’s CHFG conference will focus on: why, after a number of decades, this problem persists the barriers to patient safety improvement the possible ways these can be overcome in the future. Register
  24. Event
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    The 2022 World Patient Safety, Science & Technology Summit (WPSSTS) is co-convened by the American Society of Anesthesiologists, the European Society of Anaesthesiology and Intensive Care and the International Society for Quality in Health Care, and will celebrate the Patient Safety Movement Foundation’s first 10 years of achievements. The 2022 WPSSTS will confront leading patient safety issues with actionable ideas and innovations to transform the continuum of care by dramatically improving patient safety and eliminating preventable patient harm and death. The WPSSTS brings together all stakeholders; we need everyone to step up and be part of the solution. We invite international hospital leaders, patient and family member advocates who have experienced harm, public policymakers and government officials, other non-profits working toward zero harm, healthcare technologists, engineers, and the future of healthcare – students and residents. All stakeholders are invited to actively and intimately plan solutions around the leading patient safety challenges that cause preventable patient deaths in hospitals and healthcare organizations worldwide. The WPSSTS will also feature keynote addresses from public figures, patient safety experts, and plenary sessions with healthcare luminaries, patient advocates, as well as announcements from organizations who have made their own commitments to reach the Patient Safety Movement Foundation’s vision of ZERO preventable harm and death across the globe by 2030. Register
  25. Event
    This Westminster Health Forum conference will examine the next steps for palliative and end of life care in England. It will be a timely opportunity to assess the updated Ambitions for Palliative and End of Life Care: A national framework for local action and how its aims can be achieved. The agenda will bring out latest thinking on key priorities in the framework and wider issues, looking at: patient-centred care service delivery, local leadership, integrated care systems, and community networks tackling variation, sharing best practice and addressing inequalities regulation and quality care delivery workforce development, specialist nurse shortages, and staff retention and wellbeing the pandemic, the NHS backlog, and increased demand the evidence base, and innovative practices and technologies Register
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