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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Regina Hoffman, executive director of Pennsylvania’s Patient Safety Authority, explains why we sometimes need to look beyond the accepted 'best practice' and provide the best care instead.  
  2. News Article
    More than 60 care homes have been investigated by the care regulator for preventing families from visiting their vulnerable elderly relatives. The Care Quality Commission (CQC) said it had conducted 1,282 inspections since 8 March and had taken action against 5% of care providers about which it had “outstanding concerns” relating to visiting, and had taken further steps against 37 cases of blanket bans on visiting. The CQC was responding to criticism from the Relatives and Residents Association (R&RA) which said the regulator had failed to act to ensure that families can check whether their parents, grandparents or spouses are receiving appropriate care. The R&RA has campaigned throughout the pandemic to allow families to see their relatives, amid concerns that depriving older people of contact with loved ones led to cognitive and physical decline. Families have also been concerned that their older relatives are more likely to suffer abuse or neglect without oversight, and even in high-quality care settings relatives can be more likely to spot signs of distress or ill-health. Read full story Source: The Guardian, 16 May 2021
  3. News Article
    A number of “unusual infections” have been discovered among patients at the Royal Aberdeen Children’s Hospital (RACH), prompting investigation by an NHS trust. NHS Grampian said they were taking a “very precautionary approach” and looking for any potential links that these infections could have to the hospital environment. These precautions include relocating some procedures, with the trust also warning that there may be delays in treatment for a small number of patients. They were keen to point out that the hospital will continue to admit and treat patients as normal whilst the investigation is ongoing. An NHS Grampian spokesman explained: “While we investigate the causes of this – and whether or not there is a link to the hospital environment – we are taking a very precautionary approach. Read full story Source: The Independent, 16 May 2021
  4. News Article
    Doctors in Wales have faced bullying and disciplinary action for raising concerns over working conditions and safety, a union leader has said. Dr Phil Banfield, of BMA Wales, said doctors who complained about work, both before and during the Covid pandemic, were seen as "troublemakers". He said there are worries bullying among staff will get worse as longer post-Covid waiting lists are tackled. The Welsh government said bullying of NHS staff was "entirely unacceptable". Dr Banfield, who is chairman of the BMA Welsh consultants' committee, said staff have faced the prospect of being victimised by colleagues, or even being forced to leave the Welsh NHS, for raising concerns over bullying or health and safety. He said: "Staff are quite good at raising concerns, but they don't raise concerns if they're going get in trouble for it, or they sense nothing is going to happen. What happens is you think 'I can't be bothered'. "Decent people develop a kind of learned helplessness and it means that people who keep raising concerns stand out." Read full story Source: BBC News, 15 May 2021
  5. News Article
    Many dread being invited for their cervical smear test - but Laurie Hodierne found it exhausting to have to keep asking for appointments, and trying to chase up the result. He is one of a number of transgender men who still have a cervix but are no longer registered as female at their GP surgery. Laurie was re-registered as male without requesting it, he says. And this means he could miss out on potentially life-saving cervical smear tests because he is not automatically called up for screenings. As a doctor, Laurie worries others who might be less able to navigate the health system will simply give up trying to get their smear test. "I understand how the systems work and the language - and despite all of that I find it exhausting," he says. "You keep coming up against a brick wall. It's a healthcare inequality in the sense that you aren't able to get access to the screening programme in the same way." NHS patients registered as female are invited to a cervical-cancer screening every three years between the ages of 25 and 50, and then every five years until they are 65. But anyone who has a cervix can develop cervical cancer. The disease often has no symptoms in its early stages and can be fatal. Read full story Source: BBC News, 17 May 2021
  6. News Article
    NHS England has said GP practices must start opening their receptions and allow people to book initial face-to-face appointments — scrapping the controversial ‘total triage’ rule — for the first time since the early days of the coronavirus pandemic. Since last spring, NHSE guidance, supported by the profession, has said that face-to-face appointments must generally only take place after a phone, video or digital consultation. Many GP practice receptions have been closed to people wanting to make routine appointments. This rule was kept in place throughout last summer, despite covid circulation being low, and some health systems made the approach one of the pillars of planned post pandemic transformation. “Embedding total triage” was encouraged in 2021-22 operational rules for the NHS. The shift was seen by some as part of a move to a potentially more effective and efficient way of working. But there have been concerns about access and complaints in the media. Read full story (paywalled) Source: HSJ, 14 May 2021
  7. Content Article
    The Alzheimer’s Society has supported the development of Jelly Drops, bite-sized sweets designed to increase your water intake. Find out how they've been helping people during the pandemic.
  8. Content Article
    A fully online Master’s in Patient Safety has been launched by Imperial College London and Bayer Pharmaceuticals. The course aims to develop global leaders and changemakers in patient safety who can catalyse improvements and innovation in healthcare practice across the globe. The programme, now open to UK and international applicants for the next academic year, is a refreshment of Imperial’s previous Patient Safety MSc offering, designed to enable a more flexible approach to learning and respond to emerging healthcare needs in light of the coronavirus pandemic. The new course aligns with the updated World Health Organization’s Patient Safety Curriculum. It features best-practice frameworks from healthcare systems around the world, as well as real-world insights and case studies from a pharmaceutical setting. The programme is delivered through a combination of online learning, group learning and live virtual teaching sessions from world-leading experts in the field. Students will also have the opportunity to apply their learnings through the completion of a research study addressing a patient safety challenge.
  9. News Article
    Nearly one in five pregnant women in the UK were forced to wear a face covering during labour, according to research by a charity, despite official health guidance saying they should not be asked to do so. Women described feeling unable to breathe, having panic attacks or even being sick during labour because they were made to wear a face covering. The research was carried out by the charity Pregnant Then Screwed, who surveyed 936 women who gave birth during December. It found that 160 of those who went into labour were made to wear a face covering. This goes against current joint UK guidance, published in July 2020 by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists. The guidance says that women should not be asked to wear a face covering of any kind during natural labour or during caesarean births because of the risk of harm and complications. Read full story Source: The Guardian, 14 May 2021
  10. News Article
    Patients have come to avoidable harm after a large private provider failed to deliver thousands of medicine prescriptions, according to a report from the Care Quality Commission. Healthcare at Home, which is based in Staffordshire but provides NHS-funded care and medicine supplies to patients’ homes across the country, has been rated “inadequate” and placed in special measures. A report published today said inspectors found more than 10,000 patients missed a dose of their medicine between October and December 2020 due to problems caused by the introduction of a new information system. Reviews have found some suffered avoidable harm as a result. Read full story (paywalled) Source: HSJ, 13 May 2021
  11. News Article
    The chief medical officers of the four UK nations are set to warn about a surge in admissions of severely ill, very young children later this year, due to the resurgence of a respiratory virus which has been suppressed by anti-covid measures, HSJ can reveal. Public Health England modelling shows a possible sharp rise in cases of respiratory syncytial virus (RSV), which can cause bronchiolitis, this autumn and winter, several senior sources said. The modelling shows between 20 and 50% more cases needing hospitalisation than normal, HSJ understands. Official projections conclude that such a surge would require, at least, a doubling of paediatric intenstive care beds and a significant increase in other critlcal care resources for sick children. Most of those expected to be affected by the rise in RSV are forecast to be three years old or younger. The UK’s four chief medical officers are considering the issue and planning to write to ministers to highlight it, the sources said, while NHS England is working on a response plan, and is expected to alert local NHS leaders. Read full story (paywalled) Source: HSJ, 14 May 2021
  12. News Article
    The parents of a baby who died after medical errors are to push for a new inquest into his death, after they say a "cruel" inquest denied them justice. Hayden Nguyen died in 2016 after medics failed to treat an infection properly. However, despite the NHS trust admitting mistakes, coroner Shirley Radcliffe concluded the infant died of natural causes, after raising concerns about the hospital's initial investigation. Hayden was six days old when his parents took him to the Chelsea and Westminster hospital in west London in August 2016. He initially had a fever but rapidly deteriorated; he had a cardiac arrest and died within 12 hours of arriving there. An internal NHS investigation concluded eight errors were made in Hayden's care, and the root causes of his death were failure to identify the signs of shock and failure to act on abnormal test results. "When they had completed the investigation, they sat us down and took us through it line by line," says Alex Nguyen, Hayden's mother. "Although the content was incredibly disturbing, it was in a way healing and it helped a little bit with the grieving process." An inquest at Westminster Coroner's Court, conducted by Dr Radcliffe, followed. However, the coroner was not happy with the hospital's investigation. The hospital to issue a second report into Hayden's care, which halved the number of errors, and said the root cause of his death was the infection "which is known to have a high mortality". Armed with this second report, the coroner concluded that Hayden had died of natural causes. "What the coroner did was kill Hayden a second time," Hayden's father, Tum, told the BBC. Read full story Source: BBC News, 14 May 2021
  13. News Article
    Patients awaiting a diagnostic test are to be assessed according to risk of becoming disabled as the service tries to prioritise in the face of huge backlogs. NHS England guidance released yesterday said local teams should categorise diagnostic waits on a four-point scale so those in most urgent need are seen first. It said this would mean, “recognising that for less urgent or routine diagnostics, some patients may experience a delay”. The diagnostics data for February showed 1.15 million people waiting for a test, compared to 1.08m in February 2020 – however, the proportion of people waiting more than 13 weeks rose from 0.6% in 2020 to 28.5% this year. The number of people on the list waiting more than six weeks also increased five-fold over the year. No more than 1% of patients are supposed to wait longer than six weeks for a diagnostic test, under government waiting time standards. The NHS England guidance puts diagnostics on the same footing as elective treatment, which has been organised according to clinical priority – P1 being the most urgent P4 being the least — since shortly after the pandemic hit last year. Read full story (paywalled) Source: HSJ, 13 May 2021
  14. Content Article
    The primary objective of this multicenter, observational, retrospective study from Giacobbe et al. was to assess the incidence rate of ventilator-associated pneumonia (VAP) in coronavirus disease 2019 (COVID-19) patients in intensive care units (ICU). The secondary objective was to assess predictors of 30-day case-fatality of VAP.
  15. Content Article
    The Centers for Disease Control and Prevention (CDC) provide answers to FAQs about ventilator-associated pneumonia.
  16. Content Article
    Health Education England (HEE) has published the first NHS-wide Patient Safety Syllabus which applies to all NHS employees and will result in all NHS employees receiving enhanced patient safety training.  Written by the Academy of Medical Royal Colleges and commissioned by HEE the new National Patient Safety Syllabus outlines a new approach to patient safety emphasising a proactive approach to identifying risks to safe care while also including systems thinking and human factors. Level one and two learning materials will be available on the E Learning for Health platform for staff to access and complete from August and September 2021. 
  17. Event
    The broad aim of the webinar is to promote After Action Review (AAR) as a valuable tool to promote learning and patient safety improvement. It will: • Show how AAR can support, empower and enable teams to identify learning and good practice • Share knowledge on how to apply AAR for impact • Excite potential new users to adopt this approach Judy Walker, a leading expert in AAR and its adoption for impact in healthcare, will set the scene explaining ‘What is AAR, why is it so valuable and what helps successfully embed it in organisations.” To demonstrate that AAR is a practical and valuable ‘how to tool,’ we want to share case study evidence from healthcare clinicians and leaders. We’re looking to showcase the experience of 3 or 4 organisations, sharing why they have adopted AAR and the benefits planned and impact. Register
  18. Content Article
    In this video, Helen Hughes, Chief Executive of Patient Safety Learning, speaks to Phil Taylor, Chief Product Officer at RLDatix, about the importance of culture in achieving high reliability in healthcare. They discuss the impact of culture on incident reporting, examples of where safety culture is key to making improvements and consider what is needed to create the right safety culture.
  19. News Article
    The government is "fully committed to learning the lessons at every stage" of the pandemic, Prime Minister Boris Johnson has said. He told MPs an independent public inquiry into the handling of the pandemic would be held in spring 2022. The inquiry would place "the state's actions under the microscope", he added, and take evidence under oath. The inquiry's terms of reference have not yet been defined but would be published in "due course", he said, adding that the devolved administrations would be consulted. Mr Johnson acknowledged many bereaved families would want the inquiry to begin sooner, but said because of the threat of new variants and a possible winter surge in infections, spring next year would be the "right moment". Read full story Source: BBC News, 12 May 2021
  20. News Article
    Covid has left a toxic legacy for the NHS, with hospitals facing a huge backlog, putting lives at risk, patient groups and staff are warning. And in-depth analysis by BBC News has found: waiting lists have ballooned at some hospitals in England, with more than one out of every 10 of patients in a quarter of trusts left at least a year without treatment major disruption to cancer services, with some hospitals struggling to treat half of their patients within the target time of two months concern growing for 45,000 "missing cancer patients", after drops in GP referrals and screening services across the UK. Elaine Walsh was diagnosed with womb cancer in January. She should have been operated on within weeks, but her operation was cancelled because of the pandemic and the backlog it had caused. Elaine's story is not unique. Analysis by BBC News shows the numbers starting treatment within the target time have fallen during the pandemic. And some trusts are struggling to start treatment for even half of patients in the recommended timeframe - two months following an urgent referral from their GP. About one in every four of the patients waiting the longest has postponed treatment themselves - and nurses at the trust have been phoning and pleading with them to have treatment. This reluctance to come forward coupled with problems accessing GP and screening services at points in the pandemic is the reason why the number of patients coming forward for checks and being diagnosed has dropped. Analysis by Macmillan Cancer Support suggests across the UK there are 45,000 "missing" cancer patients. Read full story Source: BBC News, 13 May 2021
  21. News Article
    The East of England has been revealed as the worst-performing region for long ophthalmology waits, with almost half the waiting list at one acute trust already breaching the 52-week milestone. Eleven per cent of the region’s 59,000 ophthalmology patients had already been waiting more than a year for treatment at the end of February, compared to 6 per cent in London, the best performing region. West Suffolk Foundation Trust — which is in health and social care secretary Matt Hancock’s local constituency — had by far the biggest problem on this measure of any trust in England, with 42% of the waiting list (660 patients) referred for treatment more than a year ago. Papers submitted to West Suffolk FT’s board meeting in April said there were “limited option[s] for independent sector capacity” and patients were reluctant to travel to other hospitals for treatment. The trust did not respond when asked to comment. Read full story (paywalled) Source: HSJ, 13 May 2021
  22. News Article
    Virtual wards, at-home antibiotic kits and using artificial intelligence in GP surgeries are among new initiatives to be trialled as part £160m funding to tackle waiting lists in the NHS. NHS England announced the funding to aid in the health service’s recovery after the pandemic, after figures last month revealed the number of people waiting to begin hospital treatment in England had risen to a new record. A total of 4.7 million people were waiting to start treatment at the end of February - the highest figure since records began in August 2007. But NHS England said indicators suggest operations and other elective activity were at four-fifths of pre-pandemic levels in April, which is "well ahead" of the 70% threshold set out in official guidance. It said it is working to speed up the health service's recovery by trialling new ways of working in 12 areas and five specialist children's hospitals. The so-called "elective accelerators" will each get some of the £160m as well as extra support for new ways to increase the number of elective operations, NHS England said. Tens of thousands of patients in the trial areas will be part of initiatives including a high-volume cataract service, one-stop testing facilities and pop-up clinics to allow patients to be seen and discharged closer to home. Other trials over the next three months include virtual wards and home assessments, 3D eye scanners, at-home antibiotic kits, "pre-hab" for patients ahead of surgery, artificial intelligence in GP surgeries and so-called "Super Saturday" clinics, bringing multi-disciplinary teams together at the weekend to offer more specialist appointments. Read full story Source: The Independent,
  23. News Article
    A major trial to detect one of the most elusive and deadly cancers - ovarian - has failed to save lives, after two decades of work. The researchers, at University College London, said the results were a disappointment - and thanked the 200,000 people who participated. The trial had looked promising, with annual blood tests detecting cases of ovarian cancer earlier. But routine screening for the cancer is now a distant prospect. Ovarian cancer is tricky to diagnose because the symptoms are easily mistaken for less serious health problems. "Some women are diagnosed so late they are too sick to start treatment," the trial's lead investigator, Prof Usha Menon, said. The UK Collaborative Trial of Ovarian Cancer Screening - the largest in the world - tracked levels of CA125, a chemical released by ovarian tumours, in the blood and sent participants in whom they were rising for an ultrasound scan. Unfortunately the final results, published in the Lancet medical journal, showed the screening had failed to save lives. Read full story Source: BBC News, 12 May 2021
  24. Content Article
    How does putting limitations around something boost innovation and learning? It may seem counterintuitive, but there is plenty of evidence to suggest that humans respond well to having some constraints imposed upon them. Judy Walker explains further in this blog.
  25. Content Article
    The Safety Engineering Initiative for Patient Safety (SEIPS) is arguably the best known and most published systems-based Human Factors framework in healthcare worldwide. Developed by Professor Pascale Carayon and colleagues in the University of Wisconsin, the SEIPS framework is partly based on Donabedian’s well-known Structure-Process-Outcome model of healthcare quality. SEIPS is strongly grounded in a Human Factors based systems approach.
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