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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. 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
  2. Content Article
    The purpose of this study was to identify challenges in applying certain standards, techniques for the Baku Health Center in Azerbaijan.
  3. News Article
    The NHS “was largely overwhelmed” at the height of the UK’s Covid second wave in January, according to a study. New research published in Anaesthesia, a journal of the Association of Anaesthetists, revealed the scale of the pressure on hospitals during the pandemic and how stretched some units were. Based on surveys of all NHS hospitals, with more than half responding, the study found almost a third of anaesthetists were redeployed to look after critically ill patients, leaving 42% of operating theatres closed. This meant operations, including for cancer and emergency surgery patients, had to be cancelled. The research, by Professor Tim Cook, a consultant in anaesthesia and intensive care at the Royal United Hospitals Bath Foundation Trust, said: “Three-quarters of critical care units were so expanded that planned surgery could not be safely resumed. At all times, the greatest resource limitation was staff.” It is thought the findings are an underestimate of how bad the situation really was in some hospitals because the busiest units were less able to respond to the survey. Read full story Source: The Independent, 19 May 2021
  4. News Article
    Multiple concerns were being raised about an inpatient hospital for several years before it was rated ‘inadequate’ by the Care Quality Commission (CQC), HSJ has learned. Huntercombe Hospital in Maidenhead, which provides NHS-funded mental healthcare for children, was put into special measures in February after an inspection raised serious concerns over the apparent over-use of medication to sedate patients, among other issues. It has since received a further warning notice. The unit, which predominantly treats female patients, had previously been rated “good” by the CQC in 2016 and 2019. Five former patients and four parents have now told HSJ of poor care and practices at the unit between 2016 and 2020. Two of the families raised concerns directly to Huntercombe, as well as NHS England, local authorities and the local community provider, Berkshire Healthcare FT. Read full story (paywalled) Source: HSJ, 18 May 2021
  5. News Article
    Google has unveiled a tool that uses artificial intelligence to help spot skin, hair and nail conditions, based on images uploaded by patients. A trial of the "dermatology assist tool", unveiled at the tech giant's annual developer conference, Google IO, should launch later this year, it said. The app has been awarded a CE mark for use as a medical tool in Europe. A cancer expert said AI advances could enable doctors to provide more tailored treatment to patients. The AI can recognise 288 skin conditions but is not designed to be a substitute for medical diagnosis and treatment, the firm said. Read full story Source: BBC News, 18 May 2021
  6. News Article
    Serious patient safety issues are being buried in confidential hospital reports, BBC Panorama has found. Freedom of Information requests revealed 111 reports, written by medical royal colleges, which NHS trusts have a duty to share. Eighty reports were given to the BBC but only 26 had been shared in full with regulators, and 16 published. The Department of Health would not comment on whether it might change the law to ensure publication. Since the 2015 Morecambe Bay maternity scandal in which 11 babies and a mother died, NHS Trusts are supposed to publish summaries of external reviews, and share them with the regulator. An earlier review into the hospital had previously identified concerns but had not been made public. Dr Bill Kirkup, who led a 2015 investigation into the Morecambe Bay scandal, said Panorama's findings were a "great disappointment". "People should know that there is something that is important enough to be looked at and they should know what the results of that scrutiny are. I can't understand what the rationale would be for withholding the existence of a report or the findings of the report. These are important matters of accountability in the public service." Read full story Source: BBC News, 19 May 2021
  7. Content Article
    Dementia can have a significant impact on a person’s daily life, including how well they function within their home. Memory issues or problems recognising and interpreting the objects around them can cause the person frustration or create safety issues. Dementia UK have produced a leaflet with tips and guidance on how to make the home more safe for someone with dementia.
  8. Content Article
    Medical device and drug safety recalls are on the up. But is there a way to predict which products will be recalled in the future?
  9. Content Article
    Julia’s mum, Gladys, lived with vascular dementia. She was a bubbly, social woman and her care replicated that. The support Gladys received was exceptional, and now Julia would like to help families, not as lucky as her own, to receive the same. Read Julia's story.
  10. News Article
    Tens of thousands of people with dementia are taken to hospital each year for emergency admission because inadequate social care has left them unprotected from infections, falls and dehydration, an investigation has found. There has been a 27% increase over a four-year period in avoidable illnesses and injuries caused by failures in care for those living with dementia, according to the Alzheimer’s Society. “This news comes just under a week after the Queen’s speech frustratingly made only a brief mention of the prime minister’s promise nearly two years ago to deliver a clear plan for social care reform, a devastating blow for the 850,000 people living with dementia, worst hit by coronavirus,” said Kate Lee, chief executive officer at Alzheimer’s Society. The charity found that nearly two-thirds of dementia emergency admissions could have been avoided. It blames cuts in social care budgets and warned that worse is to come. Launched to mark Dementia Action Week, the charity’s investigation also found that nearly three-quarters of family carers said loved ones with dementia had experienced preventable medical issues because of lack of support. One in nine had been taken to hospital. Read full story Source: The Guardian, 17 May 2021
  11. Event
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    What will the new world of work look like in the NHS post-pandemic is the crucial question being examined in an HSJ webinar. The webinar will bring together a panel of experts to discuss what skills NHS staff will need as the world of work changes, with the likelihood that some work that has been done face-to-face will be virtual. On the panel will be Elspeth Griffiths, director of HR, workforce and OD for NHS South Central and West Commissioning Support Group, Kate Jarman, director of communications and corporate affairs, Milton Keynes University Hospital, Henrietta Mbeah-Bankas, head of blended learning and digital literacy project lead, Health Education England and Rosalind Penny, director of HR & OD, Integrated Care System for Buckinghamshire, Oxfordshire and Berkshire West. Chairing the discussion will be HSJ senior correspondent Annabelle Collins. This HSJ webinar, in association with NHS South, West and Central Commissioning Support Unit, will look at how the working lives of NHS staff – both clinical and non-clinical – will change, how to upskill existing staff with new skills and make their lives mote satisfying, and whether there are easy wins NHS organisations can aim for. Register
  12. News Article
    Ambulance crews will start using iPads to send photographs of accident and stroke victims to specialist hospital doctors so that they can make rapid diagnoses and save some patients a trip to A&E. NHS England is giving 30,000 iPads to regional ambulance services to help paramedics decide what care to give and whether to take someone to hospital or treat them at the scene. The tablet computers will be a vital link between ambulance crews and hospital consultants, whose digital interaction will make treatment faster and better, NHS England said. For example, the devices will let paramedics show an A&E department how badly injured patients have been in a road traffic crash, so that they can prepare for their arrival. They will also allow crews access to patients’ medical records to help them build a better picture of their health. “Ambulance crews have been at the forefront of the pandemic, routinely dealing with life-and-death situations and often first on scene to treat and diagnose critically ill patients,” said Sir Simon Stevens, NHS England’s chief executive. “These devices are another tool for our highly skilled paramedics and ambulance technicians as they continue to respond to the country’s most critically ill and injured patients.” Read full story Source: The Guardian, 18 May 2021
  13. News Article
    Monica Evans's initial misdiagnosis could have proved life-threatening – and she is just one of many to have suffered during pandemic. Since The Telegraph began reporting on the struggles of patients around the country to access GP services during the pandemic, they have been inundated with messages and letters. There have been multiple stories of serious misdiagnoses made after telephone consultations with doctors that took place in lieu of face-to-face assessments; of interminable waits to get through to practices on jammed phone lines; and of lengthy delays while worried patients have waited for referrals to be made. Those who shared their experiences have also shared their fury, frustration, fear and dismay. Some who could afford to have felt they had no option but to turn to private healthcare, unable to obtain the help they needed from an NHS struggling with Covid and all its knock-on effects. Others have been left with nowhere to turn. GPs have spoken, too, about their dissatisfaction with a system that has discouraged face-to-face consultations. Amid an outpouring of anger from both patients and doctors, NHS England yesterday rowed back on plans for "total triage" of patients to keep them out of surgeries whenever possible. But for many the damage has already been done. Read full story (paywalled) Source: The Telegraph, 13 May 2021
  14. News Article
    COVID-19 vaccines tend to alleviate the symptoms of long Covid, according to a large survey of more than 800 people that suggests mRNA vaccines, in particular, are beneficial. Although COVID-19 was initially understood to be a largely respiratory illness from which most would recover within a few weeks, as the pandemic wore on increasing numbers of people reported experiencing symptoms for months on end. There is no consensus definition of the condition of these people who have symptoms ranging from chronic fatigue to organ damage, let alone a standardised treatment plan. As vaccines hit the mainstream, concerns arose that vaccination could precipitate relapses or a worsening of symptoms. But conversely, anecdotal reports suggested that vaccines helped some people with long Covid. The analysis, which is yet to be peer reviewed, was conducted on the basis of a survey of 812 people (mostly white, female participants) with long Covid in advocacy groups in the UK and internationally who were contacted via social media. The participants (a small proportion of whom also said they had ME/CFS) were asked to wait at least a week after their first dose to avoid their responses conflating with side-effects of the vaccine. 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. Read full story Source: The Guardian, 18 May 2021
  15. News Article
    NHS trusts are to be told to remove devices linked to more than 120 never events caused by ‘unconscious errors’. A national patient safety alert from NHS England which urges trusts to remove all air flowmeters from wall medical gas outlets. It is likely to be published next month. The alert comes after 121 never events in the last three years involved staff members accidentally connecting patients to air instead of oxygen. This number is close to 10% of all never events recorded during that period. These types of never events have been recorded by 57 NHS organisations during 2018-19, 2019-20 and 2020-21. The incidents took place mostly on medical wards and in emergency departments. They occurred despite NHSE issuing a patient safety alert in 2016, which recommended removing the flowmeters from wall outlets when not in active use. According to NHSE documents - seen by HSJ - the never events often went undetected “for some time”, even when other staff responded to deteriorating patients or took over their care. The regulator concluded this makes it more likely that there have been other unreported incidents. Read full story (paywalled) Source: HSJ, 17 May 2021
  16. Content Article
    Surgery can be a highly demanding environment, and in pressurised situations we need to prioritise patient safety. Under these circumstances there is a need for clear leadership, but being assertive can sometimes be challenging without coming across as aggressive or intimidating. Training is also an area in which potential issues could arise. Not every trainee will develop at the required rate, and it is important to be able to address concerns with an individual without fearing being labelled as a bully. The following recommendations from the Royal College of Surgeons of Edinburgh may help with workplace relationships.
  17. Content Article
    National Guardian newsletter discussing current events, annual reports, and guidance.
  18. Content Article
    Despite many investigations and inquiries into violent incidents in mental health settings, resulting in reports and guidelines, safety considerations for mental health staff continue to be an issue of serious concern. This report from the Royal College of Psychiatrists attempts to address the safety needs of psychiatrists. Psychiatrists from different disciplines are likely to be exposed to different degrees of threat to their safety, but no particular branch of psychiatry is immune. In the same vein, the context in which psychiatric practice is delivered will also have a bearing on the likelihood of violence, be it on in-patient units, in out-patient settings, in accident and emergency departments, in prisons and other custodial institutions, or in patients’ homes.
  19. Content Article
    The Suicide Prevention National Transformation Programme aims to reduce the number of deaths by suicide in England by 10% by 2020/21.  NHS England are investing funding in 37 local areas to establish or develop their multi-agency suicide prevention action plans to reduce suicide and self-harm. These plans cover three of the main priority areas identified in the National Suicide Prevention Strategy: Reducing risk in men. Prevention and response to self-harm. Improving acute mental health care. Find out more about the programme and useful resources from the link below.
  20. Content Article
    Angie Middleton, Patient Safety Lead for Mental Health (London Region), presents on the Mental Health Suicide Report and discusses London's incident reporting. She highlights that we need to understand whether the extent to which the increase in reported incidents is as a result of more consistent reporting, or an actual increase in actual incidents or as a result of an increase in the number of patients accessing secondary mental health services. She asks whether there is a way of collectively getting timely, consistent and accurate data for multiagency use, and how we can collectively reduce suicides by 10% by 2020/21.
  21. Content Article
    The NHS is in the process of changing the way it embraces patient safety, moving from a focus on individual incidents and issues to a more comprehensive look at system learning. The changes are set out in NHS England/Improvement’s Patient Safety Strategy, released in July 2019 and updated in February 2021. This was followed by the Patient Safety Investigation Framework in March 2020, due for full implementation by Spring 2022. They are important not just in relation to incident management but also because of the implications they have for strategy and board responsibilities in relation to patient safety. So they need careful attention at all levels of NHS organisations. This article from the Good Governance Institute highlights the safety roles and responsibilities of organisations and moving to a proactive approach to safety management.
  22. Event
    Chaired by Mr Bibhas Roy Consultant Orthopaedic Surgeon Manchester University NHS Foundation Trust this conference focuses on elective surgical caseload and post recovery. The challenge of current waiting lists for elective procedures is clear, the conference will discuss practical strategies and solutions for meeting demand and ensuring safety post COVID-19 including creating clear accountability for elective recovery and improving productivity. New models will be discussed for delivering increased activity including supporting supporting trusts and clinical teams to work together across Integrated Care Systems (ICSs) to eliminate variation and embed recognised best practice, patient scheduling and prioritisation, optimising theatre utilisation and performance and developing the role of the independent sector. Register
  23. Content Article
    As COVID-19 hit England last spring, the health service faced workforce shortages of over 100,000 staff. Around 40% of the staffing shortfall was in nursing. Capacity constraints of all kinds have been an important backdrop to the management of the pandemic. Equipment and buildings matter, but throughout COVID-19 the key risk was not having enough staff to safely treat all the patients needing care. Anita Charlesworth discusses what action is now required.
  24. Content Article
    The Joint Advisory Group on GI Endoscopy (JAG) and Imperial College London are conducting a survey into the safety attitudes of all endoscopy staff across UK & Ireland endoscopy services. Your views are vital in understanding current safety practices across endoscopy nationally. This survey takes less than 7 minutes to complete.
  25. Event
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    This webinar is organised by the Fellowship of Postgraduate Medicine. The panel will review the neurological and neuropsychiatric sequelae of COVID-19, what is known about this emerging spectrum of disorders, It is timely to review what we know and don’t know about the neurological and neuropsychiatric sequelae of COVID-19, what is known about why they happen and what treatments to consider. Register
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