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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    NHS England is pushing ahead with plans to replace the NHS’s four-hour emergency target with a new set of 10 metrics, it has announced today. The announcement follows a consultation launched in December on its latest proposals, although any final plans will still require government signoff (see box below for the 10 new metrics). NHSE/I said in a press release: “In an NHS consultation four out of five respondents said they would welcome a bundle of measures. The specific proposals were endorsed by two thirds, 67%, of respondents and opposed by just 13%.” However, NHSE/I said in a report on the proposals that it had not yet been established how the new basket of metrics would be used as a performance measure and that the proposals still needed government sign-off. Read full story (paywalled) Source: HSJ, 26 May 2021
  2. News Article
    Rising numbers of patients needing care and a shortage of GPs is threatening to overwhelm the system, doctors and patient groups are warning. It comes after the pandemic has caused severe disruption to GP practices for more than a year. Analysis of NHS England data by the Health Foundation found more than 28 million appointments were booked in March, among the highest recorded. Doctor's leaders say what they are being asked to achieve is "undoable". The analysis of NHS data in England carried out by the Health Foundation for the BBC also that that between 2019-20 and 2020-21: The total number of appointments dropped by 10% - meaning 31 million fewer consultations with GPs and practice nurses Major shift from face-to-face to remote consultation, with the proportion seen in practices dropping from 79% to 54% The number of patients referred by GPs for urgent cancer check-ups dropped by 15%, putting lives at risk The escalating situation has prompted patient groups to call for an urgent review of access to services, amid reports that patients are struggling to get through. Read full story Source: BBC News, 27 May 2021
  3. News Article
    The Care Quality Commission (CQC) has revealed a new strategy that will place more emphasis on a patient’s experience of care and seek to get a better grip on ”care settings where there’s a greater risk of a poor culture going undetected”. Ian Trenholm, chief executive of the CQC told HSJ the CQC’s new approach would be informed by the belief that ”people’s experience of care is driven as much from the way different providers will interact with each other – both public sector, private sector, third sector - in a place as much as it by the individual performance of individual providers.” He repeated his pledge, made to HSJ in August, that the CQC would endeavour to make inspections less time consuming for providers. An important part of the CQC’s increased focus on patients’ experience of care would be taking more effort to determine the quality of services whose users may have trouble expressing their views, said Mr Trenholm. Read full story (paywalled) Source: HSJ, 27 May 2021
  4. News Article
    Family doctors are being forced out of their jobs after developing long Covid, prompting demands for the government to compensate NHS staff with the debilitating condition who cannot work. GPs struggling with the condition have told the Observer they felt “shocked and betrayed” when their colleagues removed them from their posts because of prolonged sick leave. “I received a lawyer’s letter on behalf of the other partners in the GP surgery telling me that they were ending my partnership. I understood why they did what they did, because I was too sick to work at the time. But it was also callous and mercenary,” said one doctor who lost her job. “It was hard on me, as one of the partners was also my best friend. The partners were worried I’d be a ‘disabled partner’ and wouldn’t be able to pull my weight. Long Covid meant I simply couldn’t function normally and so couldn’t meet the return to work date they gave me, so they exercised their right under our partnership agreement to end my partnership at the surgery,” added the GP, who asked to remain anonymous. The issue has prompted soul-searching within the medical profession about what duty of care family doctors owe each other when they cannot work because they have been laid low with exhaustion, brain fog, breathlessness and other symptoms of long Covid. Locum medics and hospital doctors with the condition are also having problems including loss of income, trouble accessing sick pay, contractual difficulties and getting employers to accept that they cannot work normally, sometimes for months. Read full story Source: The Guardian, 23 May 2021
  5. Content Article
    We are delighted to announce that Patient Safety Learning's Chief Executive Helen Hughes has been recognised by HIMSS as a global Patient Leader in digital healthcare, alongside Birgit Bauer, Tiffany McKever and Christine Von Raesfeld.
  6. Content Article
    The Personalised Care Institute (PCI) is changing the lives of patients by helping to empower them with the knowledge, skills and confidence to feel more in control of their mental and physical health. It does this by educating and inspiring health and care professionals to deliver universal personalised care that takes into account an individual’s strengths, needs and expectations, in order to deliver the right care for them. IPC set the standards for evidence-based personalised care training, providing a robust quality-assurance and accreditation framework for training providers and commissioners along with a central learning hub for health and care professional learners.
  7. Content Article
    This dissertation from Ivan Pupulidy, Tilburg University, introduces a network of practices that transformed the United States Department of Agriculture (USDA) Forest Service accident investigation.  This dissertation uses case studies to show the interweaving of organisational and individual journeys, each of which began with the strength to inquire and to challenge assumptions. The case studies show how constructed realities, including my own, were challenged through inquiry and how four practices emerged that supported sense making at both the field and organisational leadership levels of the organisation.
  8. Event
    This AHRQ webcast will introduce the new Surveys on Patient Safety Culture™ (SOPS®) Diagnostic Safety Supplemental Items. Medical offices can use the survey items as a supplement to the SOPS Medical Office Survey to assess the extent to which the organizational culture supports the diagnostic process, accurate diagnoses, and communication around diagnoses. Speakers will provide background on the importance of diagnostic safety, an overview of the development of the items, results from a pilot test in 66 medical offices, and share resources available for users. Register
  9. Content Article
    The COVID-19 pandemic has imposed extraordinary strains on healthcare workers. But, in contrast with acute settings, relatively little attention has been given to those who work in mental health settings. Liberati et al. aimed to characterise the experiences of those working in English NHS secondary mental health services during the first wave of the pandemic.
  10. Content Article
    Although most current medication error prevention systems are rule-based, these systems may result in alert fatigue because of poor accuracy. Previously, we had developed a machine learning (ML) model based on Taiwan’s local databases (TLD) to address this issue. However, the international transferability of this model is unclear. This study examines the international transferability of a machine learning model for detecting medication errors and whether the federated learning approach could further improve the accuracy of the model. It found that the ML model has good international transferability among US hospital data. Using the federated learning approach with local hospital data could further improve the accuracy of the model.
  11. Content Article
    Myla Deviren had congenital intestinal malrotation and developed a volvulus on 26 August 2015. Her mother checked the NHS Symptom finder on line and the advice was to take her to A&E but she called 111 for advice. The Health Assistant who took the call did not appreciate the significance of key symptoms due to multiplicity of symptoms described at the outset. He passed the caller on a “ warm” transfer to the Clinical Adviser whose initial reaction on hearing that the symptoms included blue lips and breathlessness was to call an ambulance, ignored her instincts and took mum through a series of digital pathways re lesser symptoms. When directly asking about the breathlessness Myla's mum put the phone close to her daughter enabling the Clinical Adviser to hear the rapid breathing herself however they did not appreciate the significance of it and did not call an ambulance. She did however pass the call to the Out Of Hours Nurse who decided that this was a case of gastroenteritis early in the call and did not appreciate the description of a child with worsening signs. Whilst the precise point at which Myla stopped breathing is not known it was sometime between when she was last seen alive approximately 06.00 and then found unresponsive at 08.00 on the 27 August 2015. She was then taken by ambulance to Peterborough City Hospital where, despite attempts at resuscitation, she did not recover a heartbeat and she died. Post mortem revealed small bowel infarction from untreated small intestinal volvulus. It is probable that with earlier transfer to hospital by ambulance and with appropriate treatment Myla would have survived. 
  12. News Article
    “Human error” resulted in a man having the wrong leg amputated at a major Austrian hospital. The error occurred when a healthcare employee marked the wrong leg for amputation during pre-surgical procedures. The mistake was not noticed anytime during the surgery, or even during the immediate postoperative period. It was recognised during a routine wound dressing change, about 48 hours postoperatively. “A disastrous combination of circumstances led to the patient’s right leg being amputated instead of his left,” the hospital’s statement said. “We would also like to affirm that we will be doing everything to unravel the case, to investigate all internal processes and critically analyze them. Any necessary steps will immediately be taken.” Read full story Source: Lansing Injury Law News, 24 May 2021
  13. News Article
    Detectives are examining a series of baby deaths at a troubled NHS trust as the number of cases being investigated by an independent inquiry nears 200 – making it one of the worst maternity scandals in NHS history. The Independent has learned officers in the serious crime directorate at Kent Police are looking at unsafe maternity care at the East Kent Hospitals University Trust and have held a series of high-level meetings, including with the Crown Prosecution Service. The discussions are believed to centre on the possibility of opening a criminal investigation and bringing charges related to corporate manslaughter and/or gross negligence manslaughter. If this goes ahead, it would be only the second time an NHS trust had faced a corporate manslaughter charge. Today, former health secretary Jeremy Hunt said he was “deeply concerned” about the new revelations and added that this latest scandal showed “deep-seated cultural and systemic issues” in maternity care. Read full story Source: The Independent, 24 May 2021
  14. News Article
    The number of children and young people waiting longer than recommended for admission to a mental health bed has increased nearly ten-fold since last summer, according to figures from one NHS region seen by HSJ. There has been major concern about worsening mental health of children and young people through the pandemic, but these are thought to be the first official figures to emerge indicating the extent of the growth in waiting times. Board papers show that, across the NHS’ South East region, from mid-March to mid-April this year, about 50 young people each week were waiting more than the recommended time for admission or transfer into a child and adolescent inpatient mental health unit. Last June, the weekly average was less than six. The papers show much of the rise was due to eating disorders referrals, which rose from five in June to nearly 30 in early March. However, other specialist services also saw rises. Read full story (paywalled) Source: HSJ, 25 May 2021
  15. News Article
    Up to 8,700 patients died after catching Covid-19 while in hospital being treated for another medical problem, according to official NHS data obtained by the Guardian. The figures, which were provided by the hospitals themselves, were described as “horrifying” by relatives of those who died. Jeremy Hunt, the former health secretary, said that hospital-acquired Covid “remains one of the silent scandals of this pandemic, causing many thousands of avoidable deaths”. NHS leaders and senior doctors have long claimed hospitals have struggled to stop Covid spreading because of shortages of single rooms, a lack of personal protective equipment and an inability to test staff and patients early in the pandemic. Now, official figures supplied by NHS trusts in England show that 32,307 people have probably or definitely contracted the disease while in hospital since March 2020 – and 8,747 of them died. That means that almost three in 10 (27.1%) of those infected that way lost their lives within 28 days. “The NHS has done us all proud over the past year, but these new figures are devastating and pose challenging questions on whether the right hospital infection controls were in place”, said Hunt, who chairs the Commons health and social care select committee. Read full story Source: The Guardian, 24 May 2021
  16. News Article
    To lower hospital readmission rates for patients with chronic obstructive pulmonary disease (COPD), UB pharmacy researcher David Jacobs has received a $962,000 award from the US National Heart, Lung, and Blood Institute to develop a real-time readmission risk-prediction algorithm. Through a five-year Mentored Patient-Oriented Research Career Development Award, Jacobs will combine social information with rich clinical data to build predictive models that will be integrated into patient-centric interventions and tested in clinical practices. If successful, the research will help clinicians provide individualized treatment at the transition from hospital to home for COPD patients, who experience high rates of early hospital readmission, says Jacobs. “Each year, 7.8 million hospital-discharged patients are readmitted, costing the United States $17 billion,” says Jacobs, assistant professor of pharmacy practice, School of Pharmacy and Pharmaceutical Sciences. “High readmission rates are linked to several quality-of-care and patient-safety factors, such as medication-related problems, inaccurate information transfer, and lack of care coordination with primary care,” he says. “Our focus will be to apply innovative informatic techniques to the development of risk prediction models for hospital readmissions that ultimately personalizes care management interventions.” Read full story Source: UBNow, 21 May 2021
  17. News Article
    New data indicates the dental crisis shows no signs of slowing, with four in five people (80%) struggling to access timely care during the last COVID-19 lockdown. Access to NHS dental care continues to be a problem for people across England, with Healthwatch recording a 22% rise in calls and complaints about dentistry between January and March 2021.   A review of 1,375 people’s experiences shared with Healthwatch found a lack of consistency across the country when it comes to accessing a dental appointment. Whilst some people were asked to wait an unreasonable time of up to three years for an NHS appointment, those able to afford private care could get an appointment within a week. Healthwatch are calling for greater ambition and urgency from NHS dental reform plans to create more equitable and affordable dental care. Imelda Redmond CBE, National Director of Healthwatch England, said: “The twin crisis of access and affordability hitting NHS dentistry means many people are not able to access timely care – and the poorest are hardest hit. Those human stories show that oral health is a social justice and equity issue." Read full story Source: Healthwatch, 24 May 2021
  18. Event
    until
    The purpose of this online event is to demonstrate how human factors as a discipline can help address Equality, Diversity and Inclusion (EDI) issues. This webinar will explore the different situations that give rise to EDI issues, including the impact of equipment positioning on wheelchair users, the impact of open plan offices on neurodiverse people, and the impact of user interface language and terminology on people with communication difficulties. It will discuss the implications of these EDI issues, including the impact on the people directly experiencing them, as well as the wider impact on society. It will uncover how human factors can make a difference in addressing these issues, including adopting a systems approach, using a participatory design process and applying specific human factors methods to enhance EDI delivery. Register
  19. Content Article
    The Healthcare Safety Investigation Branch (HSIB) held a webinar on 12 May to discuss asthma management in children, to support the launch of their recent publication: Management of chronic asthma in children aged 16 years and under. For those of you who missed the event, HSIB have made available the webinar recording, presentation slides and Q&As.
  20. News Article
    A robot paramedic is to be used for the first time to carry out chest compressions on ambulance patients to free up the emergency team who can perform other vital treatments. The device is known as LUCAS 3 and is able to deliver consistent, high-quality CPR chest compressions whilst the patient is on their journey to hospital. CPR is essential to maintaining oxygen levels in the body and flow of blood when someone is no longer breathing. South Central Ambulance Service (SCAS) is the first ambulance service in the country to use the robots, which cost about £12,000. An SCAS spokesman said: “Once paramedics arrive and begin CPR or take over from bystanders who may have initiated it, the transition from manual compressions to LUCAS can be completed within seven seconds, ensuring continuity of compressions.” Data of the event can also be collected which can be reviewed at a later date. Dr John Black, medical director at SCAS, said: “We know that delivering high quality and uninterrupted chest compressions in cardiac arrest is one of the major determinants of survival to hospital discharge but it can be very challenging for a number of reasons. “People can become fatigued when performing CPR manually which then affects the rate and quality of compressions, and patients may need to be moved from difficult locations, such as down a narrow flight of stairs, or remote places which impedes the process.” Dr Black went on to explain that these devices don’t “fatigue or change” their delivery as a human might. This means “high quality CPR can be delivered for as long as is required.” Read full story Source: The Independent, 22 May 2020
  21. News Article
    The refusal of an arm of the Scottish Government to release information about deaths in individual care homes during the pandemic has been branded “shameful” and “shocking” by opposition parties. National Records of Scotland, which is responsible for the official recording of deaths in Scotland, breached Freedom of Information legislation by refusing to release the number of confirmed and suspected COVID-19 related deaths in each of Scotland’s care homes, the Scottish Information Commissioner has ruled. While care home death figures have been published, the NRS refused to break these down by care home, citing “speculative” arguments about this release impacting care workers and the commercial interests of care home operators, the commissioner said. “This is another devastating blow for the care home residents and families who have been denied justice,” he said. “Those responsible must be held accountable and lessons must be learned. “We need a Scottish public inquiry without delay.” Read full story Source: The Scotsman, 21 May 2021
  22. News Article
    NHS England has asked hospitals to prepare for a potential further surge of covid cases reaching around half the level of first wave of the virus last year – and to seek to deliver 80% of normal elective activity throughout it, HSJ has learned. Well-placed sources said NHSE officials have held meetings in recent weeks discussing the possibility of a fourth wave of covid later this year, which modelling suggests could see up to 50% of the patient numbers seen in April last year. Trusts have been asked by NHSE officials, as part of the planning process, what resources they would need to run at 80 per cent of previous volumes of elective work if this scenario occurred. They are also taking into account that it is likely to come on top of greater non-covid emergency care demand, which has been lower then normal over the past 15 months. Read full story (paywalled) Source: HSJ, 21 May 2021
  23. News Article
    ‘Disparity ratios’ highlighting how staff with minority ethnic backgrounds are represented at different levels in each trust have been created by the national workforce race equality standard programme to help tackle ‘racist practice’ in the NHS. NHS England head of WRES Professor Anton Emmanuel said the data had been created to indicate the differences in progression between white people and those from an ethnic minority background through the ranks of each organisation. Detail of the methodology used to calculate the ratios has not been published, but it appears they have been determined by comparing the share of staff by ethnicity in different bands. Speaking at the Ambulance Leadership Forum last week, professor Emmanuel, said: “We have gone through each of the seven regions of the country and presented to them the local disparity ratios for each trust and put that into a heatmap…The whole point is to make that data digestible and actable on.” The data can be adapted to look at different points in a trust’s progression routes and can also be used with other groups, such as disabled staff. Read full story (paywalled) Source: HSJ, 24 May 2021
  24. News Article
    People are being told to wait until 2024 for dentist appointments while others are being removed from their practice lists for not making appointments sooner, according to a damning report into the state of dentistry. Dental surgeries have reported that they have thousands of people on their waiting lists, while patients are unable to access care after ringing round numerous dental surgeries, a watchdog has warned. Delays have resulted in the worsening of painful symptoms and in one instance even led to a patient needing hospital treatment after overdosing on painkillers, it said. But Healthwatch England said that some people are being offered swift private care as an alternative at the same dental practice, with some patients reporting that they felt pressured to pay for their treatment. Some practices appeared to be prioritising private care, it added. Read full story Source: The Guardian, 24 May 2021
  25. News Article
    Matt Hancock has said compensation will be paid to people people infected by contaminated blood products and their relatives if is recommended by the public inquiry into the scandal. Appearing at the inquiry on Friday, the health secretary agreed the government had a “moral responsibility” to address what had happened. As many as 30,000 people became severely ill after being given factor VIII blood products contaminated with HIV and hepatitis C imported from the US in the 1970s and 80s. Others were exposed to tainted blood through transfusions or after childbirth. On average one person is dying every four days, with approximately 3,000 haemophiliacs having died to date. The government set up a support scheme offering ex-gratia payments without any admission of liability, but has been urged to create a compensation scheme. The health secretary told the inquiry: “I respect the process of the inquiry and I will respect its recommendations, and should the inquiry’s recommendations point to compensation, then of course we will pay compensation, and Sir Robert Francis’s review on compensation is there in order that the government will be able to respond quickly to that. “But it would be wrong to pre-empt the findings of the inquiry on that basis by me giving a policy recommendation in the middle of it.” Read full story Source: The Guardian, 21 May 2021
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