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Patient Safety Learning

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  1. News Article
    Black women face a significantly higher risk of having a miscarriage than white, research suggests. The Lancet analysis of data on 4.6 million pregnancies in seven countries suggests being black increases miscarriage risk by 43%. It calls for people in the UK to be given support after their first pregnancy loss. Currently, referral to specialist clinics usually occurs after three consecutive losses only. Most countries, including the UK, do not collect statistics, but researchers estimate: 15% of pregnancies end in loss 1% of women will experience recurrent miscarriage. Some estimates of miscarriage rate are higher, but this is due to differences in how countries define pregnancy loss, which can be from a positive pregnancy test or from a scan. The report also found that women who suffered miscarriage, from all ethnic backgrounds, are more vulnerable to long-term health problems, such as blood clots, heart disease and depression. Read full story Source: BBC News, 27 April 2021
  2. News Article
    Good quality evidence is urgently needed to inform doctors on how to discontinue antidepressants safely and effectively, a Cochrane review has highlighted. An international team of researchers assessed randomised controlled trials comparing approaches to discontinuation and continuation of antidepressants in patients who had used them for depression or anxiety for at least six months. But the team reached no firm conclusions about the effects and safety of the approaches reviewed because of the low certainty of evidence from the existing studies. Read full story (paywalled) Source: BMJ, 22 April 2021
  3. News Article
    The death of a young disabled woman following a routine eye operation was partly caused by malnutrition as a result of neglect, a coroner has ruled. Laura Booth, 21, was admitted to the Royal Hallamshire hospital in Sheffield in September 2016 for a routine eye operation. She died the next month, on 19 October. Booth had a number of learning difficulties and life-limiting complications, having been diagnosed with partial trisomy 13, a rare genetic disorder, shortly after she was born. Her mother, Patricia Booth, told the inquest that her daughter stopped eating shortly after she was admitted to hospital, and that doctors ignored Laura’s attempts to communicate with them. She said her daughter consumed only rice milk and blackcurrant juice in hospital, and she kept telling doctors: “This isn’t right, she can’t survive on no food.” The coroner, Abigail Combes, concluded that Laura Booth became unwell while a patient at the hospital and, among other illnesses, “developed malnutrition due to inadequate management for her nutritional needs”. Combes said that Booth’s death “was contributed to by neglect”. Read full story Source: The Guardian, 26 April 2021
  4. News Article
    The NHS should pause the planned roll out of bookable A&E slots until a robust evaluation of the new system has been undertaken, the Royal College of Emergency Medicine president has told HSJ. The proposals were set out in NHS England’s 2021-22 planning guidance last month. The guidance say local systems should “promote the use of NHS 111 as a primary route into all urgent care services”. It instructs local systems to “maximise the use of booked time slots in A&E with an expectation that at least 70% of all patients referred to an emergency department by NHS 111 receive a booked time slot to attend”. Sites only began piloting the model late last year. But by March the new system appeared to be being actively rolled out across the service. Seventy five of England’s 126 acute trusts with a type 1 emergency departments had begun allowing patients to book appointments in A&E by calling 111, according to NHS England data published this month. But RCEM president Katherine Henderson has told HSJ that NHSE has failed to release any data on the effectiveness of the new approach. She said NHSE must pause its plans while a full evaluation of the pilots is carried out to ensure the model was delivering operational and clinical benefits before it is adopted on a widescale basis. She said: “We are very keen to see some data and clinical validation so we can robustly assess how the 111 First model is working, because, at the moment, we haven’t really seen enough to say: ‘this is something that we really need to push on with’. Read full story (paywalled) Source: HSJ, 26 April 2021
  5. Content Article
    The purpose of this study from Roberts et al. was to explore anxiety, worry, and posttraumatic stress symptoms (PTSS) in parents of children with food allergies, and to evaluate whether these three psychological outcomes could be predicted by allergy severity, intolerance of uncertainty, and food allergy self-efficacy. The study highlights the need for greater awareness of mental health in parents of children with food allergy. 
  6. News Article
    Ministers have been urged to implement a clear recovery plan to bring down the country’s patient waiting lists that have ballooned to record-breaking levels as a result of disruption from the pandemic. Labour has warned that thousands of people waiting for hospital treatment are at risk of permanent disability and losing their livelihoods and has demanded government action. Some 387,885 patients in England are waiting more than a year for hospital treatment, according to NHS data. This has increased month-on-month since March of last year when the UK was first placed into lockdown. A year ago, in February 2020, the number of people having to wait more than 52 weeks to start treatment stood at just 1,613. In total, 4.7 million patients in England are waiting for some form of treatment or healthcare service – the highest figure since records began in August 2007. Read full story Source: The Independent, 26 April 2021
  7. Event
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    Be a part of history and join leading minds to explore clinical documentation's impact on patient safety, financial sustainability, and data integrity, in Australia's inaugural CDI conference. Targeting a broad array of health care stakeholders including CEOs, CFOs, Quality Managers, clinical staff, HIMs, Coders, and Clinical Documentation Specialists in Australia, New Zealand, and the Middle East. The conference will provide invaluable networking opportunities both in person and virtually with industry experts and like-minded individuals. Register
  8. News Article
    Hospitals are putting on extra surgery sessions in the evenings and at weekends to tackle the NHS’s spiralling waiting list and cut waiting times for patients. Health trusts in England are taking the unusual step after a rise in people waiting for cancer, heart and other treatment – and especially those forced to wait more than a year – because of the pandemic. Doctors, surgeons, health charities and hospital bosses are concerned that unusually long delays in accessing care could lead to patients’ conditions worsening or becoming inoperable. NHS Providers, which represents hospitals, fears sorting out the backlog could take up to five years. Four trusts spanning 10 acute and specialist hospitals in west and north-west London have joined forces to treat each other’s patients in a move to tackle the huge numbers seeking care. Figures collated by the trusts and shared with the Guardian show how dramatically waiting lists have increased across that area, as they have across England as a whole, as a result of the widespread suspension of normal NHS care over the last year. Read full story Source: The Guardian, 23 April 2021
  9. Event
    Aimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process and safety. Register
  10. Content Article
    Improving quality is about making healthcare safe, effective, patient-centred, timely, efficient and equitable. It’s about giving the people closest to problems affecting care quality the time, permission, skills and resources they need to solve them. As we shift from the emergency phase of COVID-19 it is vital that health and care workforces are able and supported to lead radical service change and improvements through re-starting, re-designing or developing new processes, pathways and services. 
  11. Event
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    Leading Change will bring together world class speakers from a wide range or sectors to share their experiences and insights into leading change and discuss how these lessons can be translated into the delivery of better outcomes in risk industries. The conference creates a psychologically safe environment and has a format that facilitates active discussion and debate amongst the speakers and participants. Register
  12. Content Article
    In this blog for the hub, Tim McLachlan, Chief Executive of the Natasha Allergy Research Foundation, highlights the lack of support available for patients and their families who spend their lives trying to keep either themselves or their children safe. To date there has been little attention, importance and investment given to NHS allergy services and this, he says, needs to change.
  13. News Article
    Pregnant women who catch COVID-19 are over 50% more likely to experience severe complications such as premature birth, admission to intensive care and death, a major study has found. Newborns of infected women were also nearly three times more at risk of severe medical complications and close to 10% tested positive during the first few days of their life, the study of more than 2,100 pregnant women across 18 countries worldwide revealed. Scientists leading the study warned the risk to mothers and babies is greater than acknowledged at the beginning of the pandemic, and called for pregnant women to be offered a COVID-19 vaccine. Stephen Kennedy, a professor of reproductive medicine at the University of Oxford, who co-led the study, said: “We now know that the risks to mothers and babies are greater than we assumed at the start of the pandemic and that known health measures when implemented must include pregnant women. “The information should help families, as the need to do all one can to avoid becoming infected is now clear. Read full story Source: The Independent, 24 April 2021
  14. News Article
    An RAF veteran has been left with life-changing injuries after being “mutilated” by an NHS surgeon during what should have been a routine procedure. Paul Tooth, 64, has been permanently left with tubes going in and out of his body which he needs to continually recycle bile produced by his liver. The previously fit and active father-of-two has lost five stone in weight and can barely leave his house after the surgery last year. It was supposed to be a routine gall bladder removal, but the surgeon inexplicably took out Paul’s bile duct and hepatic duct, which link the liver to the intestines, as well as damaging the liver itself, making a repair impossible. Although he has won his legal battle against the Norfolk and Norwich University Hospital Foundation Trust, Paul believes what happened to him raises bigger safety questions for the trust after he learned he was one of three patients harmed by the same surgeon just days apart. The alarm was first raised by Addenbrooke’s Hospital in Cambridge where the three patients were transferred for specialist care after their initial operations. The Norfolk and Norwich trust has now admitted liability for the errors and standard of care Paul received. Read full story Source: The Independent, 25 April 2021
  15. News Article
    A trust which was heavily criticised for poor infection prevention and control last summer has been praised for making improvements. East Kent Hospitals University Foundation Trust was served with an enforcement notice by the Care Quality Commission in August last year, citing “serious concerns” about patient safety. The trust had twice the national rate of patients infected with COVID-19 after admission to hospital. But a new report, issued today, found significant improvements, with several areas of outstanding practice. The conditions imposed on the trust after last year’s inspection of the William Harvey Hospital in Ashford were also lifted, following the visit by the CQC in early March. Cath Campbell, CQC’s head of hospital inspections in the South East, said the improvements were particularly commendable as the trust had been under extreme pressure as a result of the pandemic. She said: “Leaders adopted learnings from other trusts, and from NHS Improvement which led to the development of a detailed infection prevention and control improvement plan. The trust then set up an improvement group to focus on implementing the actions in the plan and put a committee in place to review internal audit data and led improvements based on this information. “Although there were still one or two areas for improvement which we have advised the trust to look at now, overall this is a very positive report.” Read full story (paywalled) Source: HSJ, 23 April 2021
  16. News Article
    Healthcare workers have welcomed a change in scientific advice on how to protect them from coronavirus. A document by the government's scientific advisory group (Sage) says higher grade masks may be needed when caring for Covid patients. Current guidance says that thinner surgical masks are adequate, outside of intensive care units. The Department of Health said guidance "is kept under constant review" and protecting NHS staff was a priority. Some doctors described it as a "crack of light" after more than a year of campaigning for improvements. A long list of healthcare unions and professional bodies has been making increasingly desperate appeals for what are called FFP3 respirators. These are designed to filter out infectious aerosols that may be lingering in the air, particularly in close proximity to patients. Growing evidence of the risks of airborne transmission has led the government to emphasise the importance of ventilation - with the words "fresh air" now added to the public messaging. And now a technical document released by Sage concludes that healthcare workers may need higher standards of respiratory protective equipment. Read full story Source: BBC News, 24 April 2021
  17. News Article
    Health resources diverted to fight the COVID-19 pandemic have caused a major drop in critical preventative care in the US, including childhood vaccinations and lead screenings, sexually transmitted disease testing and substance abuse services. In short, many of the routine measures meant to keep Americans healthy – and keep American health from slipping further behind that of other developed, peer nations – have hit a worrying cliff. As attention has focused on the immediate crisis of the pandemic and the hundreds of thousands of lives lost in America, this other hidden crisis represents another layer of disaster that also has profound implications. “This is either the second or first worst pandemic in modern human history,” said Dr Howard Markel, a pandemic historian and pediatrician at the University of Michigan. “We knew there would be repercussions and unintended consequences.” Now, there is a “whole menu of neglect” to address as a national vaccine campaign allows people to slowly emerge from a year of lockdowns and social distancing. “There is no historical precedent for this,” added Markel. In the first few months of the pandemic alone, at least 400,000 children missed screenings for lead, a toxic heavy metal. Doctors and nurses ordered 3m fewer vaccines for children and 400,000 fewer for measles specifically. For the first time, clinics were forced to ration lab tests for sexually transmitted diseases as lab capacity and supplies were diverted to test for COVID-19. Contact tracers were also re-deployed from tracking chlamydia, gonorrhea and syphilis cases to finding people in contact with COVID-19 patients. Data from one large commercial lab showed 669,000 fewer HIV tests were processed. Compared to 2019, the lab diagnosed nearly 5,000 fewer cases of HIV. Delayed diagnosis can lead to people unwittingly transmitting the virus. Read full story Source: The Guardian, 26 April 2021
  18. Content Article
    In 2019 the Royal College of Surgeons of Edinburgh (RCSEd) carried out a survey which evidenced the extent of non-consultant hospital doctors’ concerns about different aspects of their ability to deliver out of hours care. Respondents were also asked to give examples or aspirations of best practice. This report uses this survey data and examples of best practice to provide a proactive guideline to support trainee surgeons. The survey found that there were five key areas requiring improvement for nonconsultant hospital doctors when working OOH, specifically: a) electronic systems; b) supervision; c) training; d) staffing; e) facilities. This document considers the results of the survey to make recommendations on best practice that will support non-consultant hospital doctors and protect patients out of hours.
  19. Content Article
    Understanding the issue you want to address in your work, and identifying the difference you want to make, are important first steps for impact measurement and evaluation. Articulating your outcomes (changes or benefits that happen as a result of your work) and impact (broad or longer-term effects of your work) can help you: plan new work communicate the purpose of what you do to current or potential funders and donors decide what information to collect to evaluate your programmes and services. The National Council for Voluntary Organisations (NCVO) provides tools and resources for your organisation to use.
  20. Content Article
    A theory of change is a description of why a particular way of working will be effective, showing how change happens in the short, medium and long term to achieve the intended impact. It can be represented in a visual diagram, as a narrative, or both. A theory of change can be developed at the beginning of a piece of work (to help with strategic planning), or to describe an existing piece of work (so you can evaluate it). It is particularly helpful if you are planning or evaluating a complex, initiative but can also be used for more straightforward projects. See more in our summary of the uses of theory of change. It is helpful to involve a variety of stakeholders when you develop a theory of change – you could include staff, trustees, beneficiaries, partners and funders. The development process, and the thinking involved, is often as important as the diagram or narrative you produce. The National Council for Voluntary Organisations (NCVO) provide a 'how to' guide on building a theory of change.
  21. Content Article
    While healthcare quality has been improving on average in OECD members countries, patient safety remains a central priority for policy makers and health care leaders. A growing research body has found that patient safety culture (PSC) is associated with numerous positive outcomes, including improved health outcomes, improved patient experience, and organisational productivity and staff satisfaction. Tools to measure PSC have proliferated in recent decades and are now in wide-spread use. This report includes findings from OECD countries on the state of the art for measurement practices related to PSC. Overall, measurement of PSC is prevalent across OECD countries, though the application, purpose, and tools vary. International learning and benchmarking has significant potential for better understanding and improvement of patient safety and health care quality.
  22. Content Article
    IMAGINE Citizens is an Alberta-based network of people and community-oriented partners that offers us, as health citizens, collaboration pathways to deliver person-centred healthcare. Their vision is a health system intentionally designed in partnership between citizens and other stakeholders to achieve the best possible experiences and outcomes for all Albertans in Canada.
  23. News Article
    GPs should continue to triage patients remotely and there are currently no plans for when the approach will end, NHS England has said. GP leaders have also told Pulse they believe the ‘total triage’ arrangements will continue ‘for some time’, perhaps even beyond the end of the pandemic, due to the expectation that social distancing measures will continue. However, other GPs revealed practices have stopped offering total triage because of workload pressures and the approach ‘not saving any time for some clinicians’. NHS England said remote triage should remain in place where possible – and that the contractual exception allowing practices to suspend online appointment bookings still stands. An NHS England spokesperson told Pulse it cannot yet say how long these arrangements will continue to be in place but it is committed to ensuring patients retain the option to access services digitally going forward. Practices should use remote consultations and offer patients video appointments when appropriate, while ensuring patients have clear information about how to access services, the spokesperson said. GPs should restore activity to usual levels where clinically appropriate and proactively reach out to the clinically vulnerable and those whose care may have been delayed, they added. It comes as NHS England operational guidance last month revealed plans for practices to ‘significantly increase’ the use of online consultations as part of ‘embedding total triage’ – first introduced at the start of the pandemic to reduce transmission of coronavirus. Read full story Source: Pulse, 22 April 2021
  24. Content Article
    This report from Macmillan Cancer Support takes stock of how far the UK’s health and care services still need to go on integration for high-quality, personalised cancer care to be a reality for everyone. The analysis suggests there are four key dimensions to personalised, integrated cancer care that need to be addressed: everyone with cancer can access personalised, joined-up care; people with cancer are supported by health and care professionals consistently working together; people with cancer receive personalised, integrated care across services provided by different parts of the system; and services are designed, commissioned and funded around the goal of personalised, integrated cancer care.
  25. News Article
    Extremely unwell eating disorder patients are having to be tube fed at home by their families owing to a lack of hospital beds, as the Royal College of Psychiatrists reports a rise in people being treated in units without specialist support. Leading psychiatrists are urging the government for an emergency cash investment as the pandemic has prompted a rise in demand for treatment for conditions such as anorexia, amid “desperate pressure in the system”. In interviews with the Guardian, a number of parents told of the struggles of helping a severely unwell person from home. A number of families said they had no choice but to tube feed their children at home daily. Other parents said their children had been admitted to general children’s wards, where they were being treated by staff who had no experience of eating disorders. It is unclear how many patients are being treated at home, but Agnes Ayton, the chair of the Eating Disorder Faculty at the Royal College of Psychiatrists, said she had heard of people being unable to find beds and being creative in the community: “There is desperate pressure in the system.” Read full story Source: The Guardian, 22 April 2021
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