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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Allegations of staff assaulting patients at a mental health hospital have been uncovered for a second time, one year after the Care Quality Commission (CQC) first raised concerns over potential abuse at the unit. The regulator criticised Broomhill Hospital in Northampton in a report issued this week after inspectors found details of three alleged assaults by staff against patients. The unit is run by independent sector provider St Matthew’s Healthcare, but treats NHS patients. In May 2020, the CQC placed the hospital into special measures amid concerns it was failing to protect patients against abuse. Patients had raised concerns to inspectors over poor staff attitudes and made allegations that two had physically assaulted patients. A second inspection this year was triggered by further whistleblowing concerns from patients and staff. Following the most recent inspection, which took place this February, the CQC has again raised warnings about staff allegedly assaulting patients. The staff members involved in all three incidents were dismissed and the CQC has asked the provider to inform the police of one incident. According to the report: “Staff had not always treated patients with compassion and kindness… [or] been discreet, respectful, and responsive when caring for patients. Two patients told us that their experience in the hospital was ‘terrible’. Two different patients told us that they had observed staff shout at patients. Another patient described Broomhill as ‘the worst hospital they had been in’, adding that they were not happy with the care provided.” Read full story (paywalled) Source: HSJ, 22 April 2021
  2. News Article
    Nearly 400 women who were treated by a consultant gynaecologist who "unnecessarily harmed" some patients are being invited to have their care reviewed by an independent expert. University Hospitals of Derby and Burton NHS Trust is writing to 383 patients treated by Daniel Hay. His conduct has been under investigation since 2019 after hospital colleagues raised concerns. The trust has said at least eight of his patients had been harmed. It has not provided any further information on the nature of the harm. Mr Hay worked at the Royal Derby Hospital and Ripley Hospital between 2015 and 2018. The trust initially reviewed his patients who had undergone major surgery such as hysterectomies, before being expanded to include intermediate care, including diagnostic tests. By December, 383 former patients had been included in the review. Now the trust has pledged to invite each one for a virtual meeting with an independent consultant gynaecologist to discuss their care outcome, starting with those who underwent major surgery. Read full story Source: BBC News, 22 April 2021
  3. News Article
    An antiviral typically used to treat influenza is a “good contender” for a drug that could be taken at home by people infected with COVID-19, according to a scientist who is trialling the medicine. Favipiravir, licensed as a flu treatment in Japan since 2014, has already shown potential in reducing lung damage in hospitalised Covid patients and speeding up the time taken to clear the virus from the body. But two UK trials, in Glasgow and London, are investigating whether the drug could be taken by people in the community before their disease has progressed, therefore keeping them out of hospital. The government has promised to “supercharge” the search for and development of a new generation of easy-to-take, at-home drugs that can reduce transmission and quicken recovery from COVID-19. A new taskforce, modelled on the team behind Britain’s vaccine procurement programme, is to oversee this work. It intends to deliver two effective treatments - offered in tablet form - to the public as early as autumn. Read full story Source: The Independent, 22 April 2021
  4. Image Comment
    Learning from COVID-19 medical errors.jpg
    From a recent ISMP presentation. Confusion about labelling leading to risk of over dosing
  5. Gallery Image
    Learning from COVID-19 medical errors.jpg
  6. Content Article
    During the UK’s initial response to the COVID-19 pandemic, the NHS witnessed drastic and rapid changes to the way work was done. Not only were changes implemented at an organisational level, but at a more local level, staff across the service adapted and developed methods of coping to keep the healthcare system functioning. As a result of this, ideas and innovations that emerged during the initial response may be helpful not only in the immediate future but also in the longer term. This study from Miles et al. applied a systems approach to explore the changes and adaptations to work in the physiotherapy department of a large acute trust in the UK during the initial response to COVID-19 (April 2020).
  7. Event
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    Diabetes technology, in particular real-time continuous glucose monitoring (rt-CGM) devices are revolutionising the management of type 1 diabetes (T1D). The devices provide important advances in blood glucose monitoring technology that address the unmet need for detection of day-to-day glycaemic variability and patient-specific patterns of hyper- and hypoglycaemia. Currently it is estimated that less than 5% of people with T1D are using continuous glucose monitoring to manage their diabetes1 and the access to this technology can vary significantly between clinical commissioning groups2 creating vast inequalities in access. Joining this 1 hour webinar you will see thought leaders highlight the key clinical and real-world benefits of rt-CGM use. Explore best practices for patients on intensive insulin therapy and during pregnancy and review current access criteria for diabetes technology across the UK. This interactive session is designed to bring to life the positive advances in diabetes technology and the importance of gaining access to support long term diabetes management. As well as hearing from thought leaders in diabetes, you will have the opportunity to ask questions throughout. Register
  8. Event
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    This year ISQua is holding a virtual conference. Reasons to attend: To acknowledge the hard work that the healthcare workers around the world have undertaken during the COVID-19 pandemic;. To remember those who have died and to dedicate ourselves to improve what we do, so that we will be better prepared for the next time a crisis arises. To share knowledge and to learn from the experts in the field, as well as those who deliver and receive care. To hear from the great plenary speaker line-up that we have assembled. To attend symposia on coproduction of health, external evaluation, patient safety and quality improvement, and those concentrating on work in Australia, the Netherlands and Ireland, and by the ISQua Academy; To go to over 30 one hour seminars and workshops To have the opportunity to meet the Experts. To hear the shorter presentations and to read the posters where novel ideas are presented. Full programme Registration
  9. News Article
    Fears that their data would be shared with the Home Office following the Windrush scandal left some people from ethnic minorities afraid to access cancer services during the pandemic, an NHS England document has revealed. The paper from the West Midlands Cancer Alliance said there was a “perception” the government was “accelerating immigration removals” and that, as a result, “individuals (particularly those affected by the Windrush scandal) are then fearful of accessing cancer treatment and may not participate in screening programmes for fear their information will be inappropriately shared with the Home Office”. The news comes after figures released last week showed the fall-off in referral and treatment of Black-British patients for cancer during the early stages of the pandemic was sharper than for their White-British counterparts. Referrals and first treatments for cancer dipped across the board in April last year. However, by July, White patients were receiving 77 per cent of the treatment volumes they had done 12 months before. The figure for Black patients was 67 per cent. This 10 percentage point difference continued in August and September, as treatment volumes for White-British patients recovered to 83 and 91 per cent respectively. Parity was achieved from October to December 2020, the latest period for which data is available. Read full story (paywalled) Source: HSJ, 22 April 2021
  10. News Article
    Six out of seven new mothers in England are not getting a checkup of their health six weeks after giving birth, despite such appointments becoming a new duty on the NHS last year. Just 15% of women who have recently had a child are having a dedicated consultation with a GP to discuss their physical and mental health, according to a survey by the parenting charity National Childbirth Trust (NCT). The requirement was introduced last year to boost maternal health and especially to try to identify women having psychological problems linked to childbirth such as postnatal depression. The appointments are separate to the established six-week check of a baby’s progress. However, 85% of the 893 mothers in England whom Survation interviewed last month for NCT said their appointments were mainly or equally about the baby’s health and they did not get the chance to talk to the GP about their mental wellbeing. “It is extremely disappointing to find that only 15% of new mothers are getting an appointment focused on their wellbeing and a quarter of mums are not being asked about their mental health at all,” said NCT’s chief executive, Angela McConville. Read full story Source: The Guardian, 22 April 2021
  11. News Article
    Doctors, nurses and NHS bosses have pleaded with Boris Johnson to spend billions of pounds to finally end the chronic lack of staff across the health service. The strain of working in a perpetually understaffed service is so great that it risks creating an exodus of frontline personnel, they warn the prime minister in a letter published on Wednesday. They have demanded that the government devise an urgent plan that will significantly increase the size of the workforce of the NHS in England by the time of the next general election in 2024. Their intervention comes after the latest NHS staff survey found that growing numbers of them feel their work is making them sick and that almost two-thirds believe they cannot do their jobs properly because their organisation has too few people. NHS poll shows rising toll of work stress on staff health The letter has been signed by unions and other groups representing most of the NHS’s 1.4 million-strong workforce, including the Royal College of Nursing, British Medical Association and Unison. NHS Providers and the NHS Confederation, which both represent hospital trusts, have also endorsed it, as has the Academy of Medical Royal Colleges, a professional body for the UK’s 240,000 doctors. Read full story Source: The Guardian, 21 April 2021
  12. Content Article
    As part of the Clinical Human Factors Group (CHFG)'s core mission to promote human factors science in education and training, CHFG have produced a series of E-learning modules for healthcare. These modules seek to encourage the positive actions that create patient safety that are relevant to all staff working in healthcare. We use a human factors and ergonomics perspective to show how human performance and safety are affected by the way we behave, communicate and interact at work. The learning is based around a true story re-created in a new film to show the complexity of how a patient safety incident develops in an everyday scenario. The actors illustrate the subtle behaviours, that we all do some of the time, that give rise to well-documented safety issues, as well as the safety-creating behaviours we want to encourage. The modules reflect items on the NHS England’s Patient Safety Syllabus. 
  13. Content Article
    NICE will speed up patients’ access to the latest and most effective treatments, and dynamic guideline recommendations will be put in the hands of healthcare professionals more quickly under plans unveiled by National Institute for Health and Care Excellence (NICE) in its 5-year strategy.
  14. News Article
    NICE will speed up patients’ access to the latest and most effective treatments, and dynamic guideline recommendations will be put in the hands of healthcare professionals more quickly under plans unveiled by NICE in its 5-year strategy launched on Monday (19 April 2021). NICE will transform key elements of its approach to ensure efficiency and speed while maintaining robust, trusted methods. The COVID-19 pandemic has reaffirmed the need to place science and evidence at the heart of health and care decision making and improve outcomes for all patients across the healthcare system. Ensuring the organisation is more proactive and engaged with the life science industry earlier in the innovation pathway will allow patients to access new treatments faster. Professor Stephen Powis, NHS England medical director, said: “Since its creation the NHS has always adapted quickly in response to new innovations, from world first transplants to more recently new cancer drugs and treatments during the pandemic which are enabling patients to get the care they need from the comfort of their own home." “At the heart of the NHS Long Term Plan is a commitment to rollout the latest treatments to patients as soon as they are approved and so we welcome NICE’s new strategy to speed up approvals of the latest and most effective treatments.” Read full story Source: NICE, 19 April 2021
  15. News Article
    Infant mortality is not "openly discussed" among some communities, a charity worker in Birmingham said, as the city attempts to tackle a long-standing problem. For the last decade, Birmingham has had one of the highest rates of infant mortality in England. The city council has set up a taskforce in a bid to halve the number of deaths. It heard rates were highest in deprived areas and among Black, Pakistani, and Bangladeshi heritage families. Shabana Qureshi is the women wellbeing manager for the Ashiana Community Project, a charity which works to improve quality of life for those living in Sparkbrook. Figures from the 2011 census show 87% of its population identified as being from an ethnic group other than White British, with the largest ethnic group being Pakistani. Many of women she works with, she said "don't know how to ask the right questions" and so are "not informed" about issues. Many people in the communities they work with, she said, have low education levels and are more likely to suffer with maternity health issues, but find it difficult to access services. "[Infant mortality] is not something that is discussed openly," she said. "A lot of women live within extended families and are sometimes not aware of the risks, they live with these conditions and health inequalities." She said any services which hope to tackle these problems need to involve communities, and be designed to be relatable, culturally sensitive and maintain trust. Read full story Source: BBC News, 22 April 2021
  16. Content Article
    Attached is a list of research papers on Schwartz rounds that you might find useful.
  17. News Article
    Three acute trusts have teamed up to carry out surgical procedures on hundreds of children over several weekends as part of plans to tackle waiting lists in the region. Trusts across the Bath and North East Somerset, Swindon and Wiltshire Integrated Care System are pooling resources to tackle long waits in paediatric oral and ear, nose and throat services. The initiative began on the April bank holiday weekend. Thirty-eight of the longest waiters from Royal United Hospitals Bath Foundation Trust, who had been waiting up to 74 weeks for oral surgery, were treated by Salisbury FT. The other trust involved in the plans is Great Western Hospitals FT. More than 400 children are expected to be treated over a series of joint surgery weekends. The next, which will also focus on both oral and ENT surgery, will take place over the early May bank holiday. RUH’s chief executive Cara Charles-Barks told HSJ the joint surgery plans will have a “huge impact” on the region’s elective waiting lists. Read full story (paywalled) Source: HSJ, 21 April 2021
  18. News Article
    New powers given to the health secretary as part of proposed legislation could make local services unsafe, NHS Providers has warned the House of Commons health select committee. In a letter to committee chair Jeremy Hunt, seen exclusively by HSJ, the membership organisation said proposed new powers over local reconfiguration outlined in the government’s recent health white paper must include an “explicit” test that proves the intervention will not worsen patient safety. The letter, signed by Chris Hopson and Saffron Cordery, CEO and deputy CEO respectively of NHS Providers, said: “Given the overwhelming importance of patient safety in these considerations, there should be an explicit test that use of the [reconfiguration] power must maintain or improve safety before the power can be exercised." “As part of the exercise of the power, the providers and integrated care system concerned, NHS England and the public should all be consulted on the relevant safety issues before the power can be exercised, with those views then made public.” Read full story Source: HSJ, 20 April 2021
  19. News Article
    Raw sewage flooding wards, power failures, and rat infestations were just some of more than 1,200 critical incidents at NHS trusts in the past year caused by ageing equipment and crumbling infrastructure. NHS leaders have said more investment is needed to reverse a backlog in buildings maintenance across the health service which has now reached an unprecedented £9bn. The situation is getting worse, with the backlog costs rising by 60 per cent in four years. In some hospitals the problems have become so severe they are affecting patient care leading to wards being closed, operations delayed and in some cases posing genuine risks to safety. Hampshire Hospitals was forced to suspend some services because of an uncontrollable rat infestation, while at East Cheshire NHS trust a power failure led to a back-up generator causing a fire triggering a second blackout. Patients had to be transferred to neighbouring hospitals and given blankets while others were given blankets to keep them warm. In another incident at Great Western Hospitals Trust, a patient having a hip operation was left under anaesthetic “open and exposed” while staff struggled to find a vital part needed for the operation which was in a storeroom that couldn’t be opened. Read full story Source: The Independent, 20 April 2021
  20. News Article
    The mother of a man who died after suffering neglect said she felt "extreme distress and anger" at a critical new report into his care home. James Delaney, 37, died while he was a resident at Sapphire House in Bradwell, Norfolk, in July 2018. After an inadequate rating by the Care Quality Commission (CQC), Mr Delaney's mother said she felt lessons had not been learned from her son's death. A spokeswoman for operator Crystal Care said it had "addressed all concerns". Mr Delaney, who died of a diabetes-related illness, was required to take insulin twice a day, but, despite staff noting he had not taken insulin for three days, they failed to take action. Jacqueline Lake, senior coroner for Norfolk, said at his inquest in 2019 there had been "a gross failure" by the care home to provide "basic medical attention". The home, which houses up to five people who have a learning disability or autistic spectrum disorder, was inspected in January and February 2021 after two whistleblowers alleged that abusive practices were taking place - a claim which is being investigated by the local safeguarding team. CQC inspectors found "people were not safe and were at risk of avoidable harm", and while risk assessments for diabetes, medicines and behaviour management existed, information was often "lacking or inaccurate". After reading the report, Mr Delaney's mother, Roberta Conway, said her reaction was one of "extreme distress and anger". She said the coroner had "pointed out what needed to be done, and it hasn't been done". "It cost my son his life and I don't want to see anybody else's life being wasted," she added. Read full story Source: BBC News, 21 April 2021
  21. Content Article
    “We have to create the culture of learning; the culture of having a safe space, the culture of wanting to do better and learning those conditions in which we do do better” This powerful talk looks directly at how a clear approach to patient safety really can improve the standard of care where you work. What is the culture of quality and safety that you’re trying to embed, can you actually do better? Learn why it’s important to focus on psychological safety; “if people start being scared, everyone gets scared then it expands”. Learn how an evidence based approach can allow us to tackle these issues rather than shy away from them; “what factors are maintaining safety? How do we get to good outcomes? What are the things working well? How do we understand human variation?”. Presented by Lee Fleisher, Emeritus Professor of Anesthesiology and Critical Care, University of Pennsylvania.
  22. News Article
    Almost 20% of patients seen by neurology consultant Dr Michael Watt were given a wrong diagnosis, a report has found. A review of 927 of Dr Watt's high-risk patients found 181 people received a diagnosis described as "not secure", Health Minister Robin Swann said. He was speaking as the Belfast Trust announced the recall of a further 209 neurology patients seen and discharged by Dr Watt between 1996 and 2012. This is the third such recall. Dr Watt was at the centre of Northern Ireland's biggest patient recall linked to his work at Belfast's Royal Victoria Hospital. Mr Swann said he had met patients and families affected by the recall in October last year. "While this report is statistical in nature, it deals with individuals, their families and their experiences," he said. "I know that many will have had their confidence in our health service shaken and I remain committed to helping restore it." Read full story Source: BBC News, 20 April 2021
  23. Content Article
    Infection preventionist, JoAnn Adkins, psychologist, Dr Lily Brown, and mother of a son with autism, Susan Senator, share their insights into how vaccines work, how to recognise when anxiety may be clouding our judgment, and how both sides of the vaccine debate can finally have a real and productive debate.
  24. Content Article
    The King's Fund report is intended primarily for hospital board members, clinicians and managers in hospitals. We hope that it will contribute to and provide support for their continuous efforts to improve patients’ experience, and that it will also be of interest to patients and their representatives, commissioners and policy-makers. The purpose of the report is to consider how we can improve the patients’ experience of care. The report introduces current debates and dilemmas in relation to patients’ experience of care in hospital, presents our view of the factors that shape that experience, and assesses the evidence to support various interventions that are designed to tackle the problems.
  25. Content Article
    The COVID-19 pandemic has profoundly impacted the country’s health systems and diminished its capability to provide safe and effective healthcare. This article from Sharda Narwal and Susmit Jain attempts to review patients safety issues during COVID-19 pandemic in India, and derive lessons from national and international experiences to inform policy actions for building a ‘resilient health system’
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