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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    It will take years to unpack how badly the pandemic damaged our collective mental health. But what we know now is no one is immune. Healthcare providers, grocery store workers, executives, stay-at-home parents, food service workers: We’re all suffering in some way. In 2019, 10.8% of adults in the United States reported symptoms of anxiety or depression. By December 2020, that number had skyrocketed to 42.4%. Regina Hoffman, Director of Patient Safety Authority, talks about the importance of self-care and gives her top three tips.
  2. News Article
    A glitch in the government’s £37bn test-and-trace system may have helped fuel the spread of a highly-transmissible Covid variant in one of the UK’s worst-hit towns, it has emerged. The software error meant that more than 700 infected people and their close contacts were not promptly passed on to local health teams, allowing them to potentially spread the disease further. The number of missing cases was highest in Blackburn with Darwen, where about 300 people are believed to have been lost in the system during a faulty IT upgrade. The Lancashire town is battling one of the UK’s largest outbreaks of the fast-spreading variant first identified in India. Labour has described the news as “jaw-dropping”. Read full story Source: The Guardian, 20 May 2021
  3. Content Article
    A joint National Patient Safety Alert issued by the NHS England and NHS Improvement National Patient Safety Team and Royal College of Emergency Medicine, on the need for urgent assessment/treatment following ingestion of ‘super strong’ magnets.
  4. Event
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    The aim of this King's Fund event is to explore the role of communities in health and care. We will bring together health and care professionals, community organisations, innovators, commissioners, researchers and policy makers interested in how to create sustainable, community-based health and care. This event will showcase projects that are innovative, scaleable and have evidence of impact on the health and wellbeing of the communities they serve. Themes include: strengthening community resilience health and care organisations ‘working with’ communities rather than ‘doing to’ sharing power and resources with communities to drive better health working with diverse communities to tackle inequalities in health. Register
  5. Content Article
    Nine out of 10 medical professional bodies think patients have a right to know if their doctor had financial or other links with pharmaceutical or medical device companies. Abi Rimmer considers the next steps towards implementing a mandatory register of doctors’ interests in the UK.
  6. Content Article
    Joe Rafferty, Chief Executive of Mersey Care NHS Foundation Trust, explains Mersey Care's strategy to pursue 'perfect care' and why it requires a cultural shift that is dependent on a paradigm shift in mind-set, behaviour and practice.
  7. Event
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    Cardiovascular disease (CVD) has become a significant long-term focus for the NHS. Given that CVD is largely preventable it is the single biggest area where the NHS can save lives over the next decade. By embracing digital technology, we can continue to close the gap in identifying people who are living undetected with high-risk conditions, such as Atrial Fibrillation. Chaired by Helen Williams - National Specialty Adviser for CVD Prevention at NHS England & Improvement, this webinar will highlight new approaches that show how the adoption of innovative ECG technology in both Primary Care investigations and Secondary Care detection and palpitation monitoring can improve efficacy and provide cost savings to the NHS and social care. Register
  8. Event
    This one day masterclass will focus on how to use behavioural insights and 'Nudge Theory' to look at patient safety and safety culture. "Nudge Theory is based upon the idea that by shaping the environment, also known as the choice architecture, one can influence the likelihood that one option is chosen over another by individuals. A key factor of Nudge Theory is the ability for an individual to maintain freedom of choice and to feel in control of the decisions they make. " Imperial College London, What is Nudge Theory? Nudge-type interventions have the potential for changing behaviours. This masterclass will look at examples of Nudge Theory use in healthcare and external organisations and how we can use these to improve patient safety and also to reduce inefficiency and waste. We will look at the type of interventions suitable for nudges and how to develop them. Key learning objectives: Behavioural Insights. Nudge Theory. Use of nudge theory to improve patient safety. Developing nudges. Opportunities for Nudge-type interventions. Register hub members receive a 20% discount. Please email info@pslhub.org for discount code
  9. News Article
    A new wave of coronavirus infections could throw into jeopardy efforts to clear a backlog of surgery in the NHS, experts have warned. They say the relaxation of Covid restrictions is expected to cause a rise in infections, while at least some resurgence in hospital admissions and deaths is also expected at some point. However, the sharp rise in cases of a variant of concern first discovered in India, B.1.617.2, has caused consternation, with modelling suggesting that if it is as transmissible as some estimates suggest, it could fuel a serious “third wave”. Now experts have said that a new wave of infections may cause further problems, exacerbating what has already been described as “a truly frightening backlog” of care. “We are anticipating that as lockdown is eased that cases are going to go back up slightly, that is with or without the Indian variant,” Dr David Strain, a senior clinical lecturer at the University of Exeter medical school, told the Guardian. “The biggest concern we’ve got is that if these [Covid case] numbers do start to go up, it will put a strain on trying to get other services up and running.” “GPs are crying out under the stress at the moment … we still have people not having their operations: we have had procedures postponed for over 12 months, and we have got longer waiting lists that ever before,” he said. Read full story Source: The Guardian, 20 May 2021
  10. News Article
    The health secretary will face questions about compensation for victims of the contaminated blood scandal on Friday afternoon. Matt Hancock will give evidence at a public inquiry into what's been called the worst NHS treatment disaster. Around 3,000 people have died after being given blood containing HIV and hepatitis C in the 1970s and 1980s. Ministers announced a public inquiry into the scandal in 2017 after decades of campaigning by victims and their families. Nearly 5,000 people with the blood disorder haemophilia were infected with potentially fatal viruses after being given a clotting agent called Factor VIII. Much of the drug was imported from the US, where prisoners and other at-risk groups were often paid to donate the plasma used to make it. Victims included dozens of young haemophiliacs at a boarding school in Hampshire who died after contracting HIV as a result. Tens of thousands more victims may have been exposed to viral hepatitis through blood transfusions after an operation or childbirth. Read full story Source: BBC News, 21 May 2021
  11. News Article
    GP practices should not switch off their online consultation systems outside of core hours as it will “reduce patient satisfaction”, according to NHS England. It comes in controversial new guidance issued amid a row over GP access. NHSE issued the new “standard operating procedures” this afternoon. HSJ revealed last month that large numbers of overwhelmed GP practices were turning off their online consultation services at weekends after the recent boom in digital appointments uncovered an ‘unmet demand’, leading to large numbers of queries to deal. But the new SOP says: “Patients should be able to make requests in an online system at any time.” Disabling the system outside of core hours, which some practices have done to help manage demand, is “less convenient” for patients and would “reduce satisfaction”, it says. Read full story Source: HSJ, 20 May 2021
  12. Content Article
    The aim of this study from Gurol-Urganci et al. was to determine the association between COVID-19 infection at the time of birth and maternal and perinatal outcomes. Covid infection at the time of birth is associated with higher rates of fetal death, preterm birth, preeclampsia and emergency Caesarean delivery. There were no additional adverse neonatal outcomes, other than those related to preterm delivery. Pregnant women should be counseled regarding risks of covid infection and should be considered a priority for vaccination.
  13. News Article
    A large UK study suggests having coronavirus around the time of birth may increase the chance of stillbirths and premature births - although the overall risks remain low. Scientists say while most pregnancies are not affected, their findings should encourage pregnant women to have jabs as soon as they are eligible. The majority are offered vaccines when they are rolled out to their age group. The study appears in the American Journal of Obstetrics and Gynecology. The research, led by the National Maternity and Perinatal Audit, looked at data involving more than 340,000 women who gave birth in England between the end of May 2020 and January 2021. Researchers say a higher risk of stillbirth and prematurity, as well as a greater chance of having a Caesarean section, remained even once factors such as the mother's age, ethnicity, socio-economic background and common health conditions were taken into account. Babies born to women who tested positive were more likely to need special neonatal intensive care because they were born early and needed more support - rather than being infected with coronavirus itself. Professor Asma Khalil, co-author of the paper, said it was important for women and healthcare workers to be aware of the potential risks. Read full story Source: BBC News, 21 May 2021
  14. News Article
    Coroners have warned the NHS nearly a dozen times in recent years that a lack of imaging capacity could lead to more deaths, HSJ can reveal. Five of these warnings followed deaths at a single site, Tameside General Hospital in Greater Manchester. The most recent case concerned a patient that died after developing covid during a prolonged wait for an MRI scan. Sir Mike Richards last year warned in a major report for NHS England about the lack of imaging equipment, and the Royal College of Radiologists has highlighted national shortages of radiology staff on numerous occasions in recent years. HSJ combed through more than 100 prevention of future death reports and responses published between 2018 and 2021 in an effort to quantify harm linked to these shortages. Of dozens of reports mentioning imaging issues, including software problems, poor note-taking and incorrect interpretation of results, HSJ identified 11 cases where coroners specifically warned either the trust or system concerned, and/or NHS England or the Department for Health and Social Care, that capacity issues could lead to future deaths. In some of the cases, coroners concluded that shortages likely contributed to a patient’s death. Read full story (paywalled) Source: HSJ, 20 May 2021
  15. Content Article
    Jordan is a middle-income country located in the Middle East. Health services in Jordan are provided by the public and private sectors Jordan's health indicators have been internationally lauded. In 2010, Jordan was ranked the leading medical tourism destination in the Arab world and fifth globally by the World Bank. In 2003, the Minister of Health and other health sector leaders from the RMS, the Private Hospital Association (PHA), the healthcare professional councils, and medical schools met to discuss how to address some of the health system challenges and how they might improve the quality of healthcare services. In 2007, the bylaws of the new organization were endorsed by all sectors, and in December of that year, the Health Care Accreditation Council (HCAC)—a private, non-profit, shareholding company—was created to act as the national healthcare accreditation agency of Jordan.  The mission of the HCAC was to foster the continuous improvement of the quality and safety of healthcare facilities, services, and programs through developing internationally accepted standards, building capacity, and awarding accreditation.
  16. Content Article
    Medical error is a serious issue in hospitals in Jordan. This study from Suliman et al. explored Jordanian nurses' perceptions of the culture of safety in their hospitals. The Hospital Survey of Patient Safety Culture translated into Arabic was administered to a convenience sample of 391 nurses from 7 hospitals in Jordan. The positive responses to the 12 dimensions of safety culture ranged from 20.0% to 74.6%. These are lower than the benchmarks of the Agency for Healthcare Research and Quality. Jordanian nurses perceive their hospitals as places that need more effort to improve the safety culture.
  17. Content Article
    Ensuring safe vascular access is a fundamental part of the care of many hospital patients with up to 90% of inpatients requiring intravenous access for delivery of fluids and medication or blood sampling. Historically vascular access has been carried out by anaesthetists, radiologists and medical consultants. But an HSJ roundtable heard that introducing specialist teams to assess patients for vascular access, and then insert, care and maintain devices has many advantages from both an organisational perspective and that of the patient.
  18. Content Article
    Resilient Healthcare is an emerging theoretical field that has developed with influence from engineering, safety science, psychology, ergonomics, human factors, and aeronautics. Resilient Healthcare research has centred on understanding and improving the quality and safety of healthcare delivery. Theory is increasingly well-developed, but so far has only been applied in limited ways with select settings and activities. In order to improve the quality and safety of healthcare, it is essential to first understand the sources of complexity in clinical work. This ethnographic study from Sanford et al. of five hospital teams in a large, teaching hospital in central London aims to contribute to this growing evidence base by presenting data on specific challenges faced by healthcare workers and the adaptations they use to overcome them in everyday clinical work. This paper will present a new framework for recognising misalignments between demand and capacity and corresponding mechanisms for adaptation, which can be used to understand work-as-done in complex settings and to manage risk.
  19. Event
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    The HIMSS21 & Health 2.0 European Health Conference will bring the best of both worlds: HIMSS's knowledge, expertise and thought leadership in healthcare digitisation, and Health 2.0's network of entrepreneurs and investors showcasing the latest and most innovative health tech solutions. Featuring best practices and thought leadership amongst Europe, this digital event encompasses virtual engagement for attendees as the world makes the transition to a new normal. Network with forward-thinking peers and solutions providers exploring innovative approaches to collaborations, sustainability and precision and transforming health and care in Europe. Register
  20. Content Article
    In March 2021 the advocacy group LongCovidSOS launched a survey in partnership with the University of Exeter and University of Kent to find out how people with Long Covid respond to COVID-19 vaccines. The analysis, which is yet to be peer reviewed showed that 56.7% of respondents experienced an overall improvement in symptoms, with 24.6% remaining unchanged and 18.7% reporting a deterioration in their symptoms. In general, those who received mRNA vaccines (Pfizer/BioNTech or Moderna) reported more improvements in symptoms, compared with those who got an adenovirus vaccine (Oxford/AstraZeneca). In particular, those who received the Moderna vaccine were more likely to see improvements in symptoms such as fatigue, brain fog and muscle pain, and less likely to report a deterioration, the analysis found.
  21. News Article
    Changes to vascular services in north Wales must be reversed urgently after a report highlighted safety risks, campaigners warned. Services were centralised from Ysbyty Gwynedd to Ysbyty Glan Clwyd - about 30 miles away - in April 2019. An independent report, by the Royal College of Surgeons, highlights bed shortages and confusion over staffing levels. Betsi Cadwaladr health board said it was making urgent changes to services. In the report, commissioned by BCUHB after patients and staff raised fears about the new service, the Royal College of Surgeons makes nine "urgent recommendations to address patient safety risks". The report sets out issues, including too many patients being transferred to the hub hospital at Glan Clwyd, and a lack of vascular beds leading to frequent delays in transfers. The report also refers to a lack of clarity regarding the availability of consultant vascular surgeons. Read full story Source: BBC News, 20 May 2021
  22. News Article
    Almost a fifth of nurses who left the profession cited a negative workplace culture as a reason for leaving along with almost a quarter saying they were under too much pressure. The nursing regulator, the Nursing and Midwifery Council (NMC) warned there could be an exodus of registered nurses after the coronavirus pandemic in its latest annual report. Despite a record number of nurses and midwives joining the profession across the UK, the NMC said pressure on frontline nurses could drive many away. In a survey of 5,639 nurses who left the register between July 2019 and June 2020, the NMC found that after retirement as the most common reason for leaving, almost a quarter of nurses (23%) said they left their jobs because of "too much pressure", leading to stress and poor mental health. A total of 18% blamed a negative workplace culture as the reason to leave. The NMC report warned: “These issues existed before the pandemic, and may well outlast it, further disrupting an already fatigued nursing and midwifery workforce. If not addressed, this could have a significant impact on the number of people we report leaving our register over the next year and beyond.” Read full story Source: The Independent, 20 May 2021
  23. News Article
    More than 2,500 women who were victims of the PIP breast implant scandal should receive compensation, a French appeal court has decided. It also upheld an earlier judgement finding German company TUV Rheinland, which awarded safety certificates for the faulty implants, negligent. The case in Paris involved 540 British women, who said they suffered long-term health effects. The results could have far-reaching implications for other victims. Jan Spivey is one of the women in the case. She was given PIP implants after she had a mastectomy due to breast cancer. She developed sore and aching joints, chest and back pain, fatigue, severe headaches and anxiety. Once removed it was clear her implants had been leaking silicone into her body. She says the implants have had a massive impact on her mental health. "My PIP implants from 20 years ago are still impacting on my life and my health and my wellbeing, even today." Read full story Source: BBC News, 19 May 2021
  24. News Article
    Beth and Dan Wankiewicz want answers about why their baby son Clay died last year, shortly after his birth at Doncaster Royal Infirmary. Despite a low-risk pregnancy, the family say Clay died from multiple skull fractures. Doncaster and Bassetlaw NHS Foundation Trust said "the provision and delivery of high-quality" care is a priority. The BBC has found a 2016 review flagging concerns about the hospital's maternity care was never published. The report - one of scores of unpublished reports discovered by a Freedom of Information request by BBC's Panorama programme - highlighted significant patient safety concerns. Beth Wankiewicz was admitted to hospital last July, but after a day of labour her baby had still not been born. With no consultant doctor on site, a junior doctor made two attempts to deliver the baby with forceps, after getting advice on the phone. Father, Dan, remembers the second attempt with forceps being much more vigorous "which was a bit of a shock". The family say there was a further delay before they had a Caesarean section. Their baby had to be pushed back up the birth canal into the womb for the C-section to be performed. "I think after about 10 minutes, we both looked at the clock, and we said it's not looking good," said Dan. Around 20 minutes after their son was born, despite attempts to resuscitate him, they were told he had died. The following day they say a midwife told them she was being pressurised by other staff to say Clay had been stillborn, but she was sure he had been born alive, and she had heard a heartbeat. The family now believe this was to avoid scrutiny and the need for a coroner's inquest, which doesn't happen with still births. Read full story Source: BBC News, 19 May 2021
  25. News Article
    A Virginia gynaecologist has been sentenced to 59 years in prison for a fraud scheme that caused insurance programmes to lose more than $20 million, according to the U.S. Justice Department. Javaid Perwaiz was sentenced after being convicted last November of 52 counts of healthcare fraud and false statements related to a scheme in which he performed medically unnecessary surgeries, including hysterectomies and improper sterilisations, on his patients. From about 2010 to 2019, Dr. Perwaiz often falsely told his patients that they needed the surgeries because they had cancer or could avoid cancer, prosecutors said. Additionally, evidence showed Dr. Perwaiz falsified records for his obstetric patients to induce labor early to ensure he was reimbursed for the deliveries and violated Medicaid's required 30-day waiting period for elective sterilisation procedures by backdating records to make it appear that he had complied with the waiting period. Dr. Perwaiz also billed insurance companies for diagnostic procedures that he only pretended to perform at his office, prosecutors said. "Motivated by his insatiable and reprehensible greed, Perwaiz used an arsenal of horrifying tactics to manipulate and deceive patients into undergoing invasive, unnecessary and devastating medical procedures," Raj Parekh, acting U.S. attorney in the Eastern District of Virginia, stated. "In many instances, the defendant shattered their ability to have children by using fear to remove organs from their bodies that he had no right to take." Read full story Source: Becker's Hospital Review, 18 May 2021
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