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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The Once for Wales Concerns Management System Programme was developed from the recommendations made by Keith Evans in the Welsh Government report – “The Gift of Complaints” and is aimed at bringing consistency to the use of the electronic tools used by all NHS Wales health bodies. All organisations currently have varying versions and modules of the DatixWeb and DatixRichClient systems. Following a successful competitive tender, which really tested and explored the market, RLDatix Ltd have been awarded the contract for 5 years, with an opportunity to extend this period if it is successful. The solution is known as DatixCloudIQ and has many enhanced features compared to other systems. It is a new Datix.
  2. Event
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    COVID-19 has been incredibly stressful—personally and professionally—and has profoundly affected everyone in healthcare, including those of us in patient safety, quality, and risk management. Grab a cup of coffee or tea and join this virtual round table to decompress and share your experiences. Some of your colleagues have offered to discuss their coping strategies, and please feel free to do the same. We will also be providing resources from professionals trained to handle stress. Register
  3. Event
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    On 29 November 1999, the Institute of Medicine released a report called To Err is Human: Building a Safer Health System, the report reviewed the status of patient safety in the US and UK, 20 years on and the NHS have released The NHS Patient Safety Strategy. Within the newly developed strategy, the NHS has three strategic aims that will support the development of patient safety culture and a patient safety system. Register
  4. Event
    Join the Airport Training Experts Miroslav SPAK and Frederic Rooseleer for a 90 minutes live training session. Enhanced operational efficiency and sustainability can be achieved by optimising the current operations through implementation of advanced solutions maximizing utilisation of the airport capacity. These solutions have been initially developed and validated under SESAR, and recently packaged by EUROCONTROL to cover Runway Performance, Surface Management and Total Airport Management. This webinar will provide information on the total airport management building blocks and also a review of the key runway performance solutions available for deployment as well as their benefits, supporting implementation needs and reference material. Register
  5. Content Article
    Patient safety and digital experts have given their views on immediate digital priorities that could make a significant difference in the NHS.
  6. Content Article
    Buildings have been associated with spread of infectious diseases, such as outbreaks of measles, influenza, and Legionella. With SARS-CoV-2, the majority of outbreaks involving three or more people have been linked with time spent indoors, and evidence confirms that far-field airborne transmission (defined as within-room but beyond 6 feet) of SARS-CoV-2 is occurring. In this paper, Allen et al. discuss how controlling concentrations of indoor respiratory aerosols to reduce airborne transmission of infectious agents is critical and can be achieved through source control (masking, physical distancing) and engineering controls (ventilation and filtration).
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  8. News Article
    A child was twice given double the "safe" dose of a rapid tranquilizer at a hospital run by a troubled NHS trust. The child was put at "significant risk of harm" at Telford's Princess Royal Hospital, said inspectors. Rating children's services inadequate, they said Shrewsbury and Telford Hospital NHS Trust (SaTH) must halt seeing under 18s for acute mental health needs. The trust, in special measures, was working to "urgently address concerns". The Care Quality Commission (CQC) carried out a targeted inspection on 24 February prompted by "concerning information" about treatment at the service run by SaTH. The trust is currently at the centre of the largest ever inquiry into NHS maternity care. Staff told inspectors they had seen an increase in the number of young people with "significant mental health issues" and learning disabilities over the past year. But the services, which were rated as "requiring improvement" in November 2019, were deemed "inadequate" in four of five areas tested - for being safe, effective, responsive and well-led. Read full story Source: BBC News. 19 April 2021
  9. News Article
    Patients have been significantly harmed, including suffering permanent damage to their liver, after being given accidental overdoses of paracetamol in hospital. The NHS safety watchdog the Healthcare Safety Investigation Branch (HSIB) has now launched a national investigation after a number of incidents where adults with a low bodyweight were given too much paracetamol through an infusion, or IV drip, directly into their bloodstream. The Independent understands there were three incidents reported by NHS staff in 2020 but there have been others in earlier years including the trigger event which sparked HSIB’s probe. Overdoses of IV paracetamol in both adults and children is a recurring problem. Safety alerts have been repeatedly issued to NHS hospitals over the problem, with one alert in 2010 highlighting more than 200 previous incidents of overdoses. In 2011 an inquiry into the death of 19-year-old Danielle Welsh, who died from liver failure due to a sustained paracetamol overdose in June 2008, found a junior doctor who prescribed the drug did not know she weighed only 35kg. The inquiry found: “There was a prevailing culture of assumed familiarity with the administration of IV paracetamol, a familiarity derived from the common use of oral paracetamol.” Now the independent Healthcare Safety Investigation Branch believes the problem of prescribing paracetamol without considering a patients’ weight is still going on. Read full story Source: The Independent, 19 April 2021
  10. News Article
    A London-wide operation has launched known as Operation Cavell, to improve the safety of NHS staff. The initiative will see a senior officer review all reports of assaults and hate crime against NHS staff. Following a three-month pilot, the NHS, Metropolitan Police Service (MPS) and Crown Prosecution Service (CPS) have been working in partnership to launch the scheme, which aims to protect NHS staff on the frontline. As well as senior police officer involvement, senior welfare and support staff within the NHS will be brought on board to help those who have been the victim of such crimes feel safer. Martin Machray, Joint Regional Chief Nurse for NHS England & Improvement in London, said: “The last year of the pandemic has shone a light on the selflessness and dedication of NHS staff. All our staff should be able to come into work without fear of violence, injury or abuse. We therefore welcome the rollout of this important initiative across mental health services in London and we hope it will help protect and support our wonderful colleagues.” Read full story Source: National Health Executive, 16 April 2021
  11. News Article
    Regulators have sent an improvement director into a North West acute trust amid multiple allegations of poor care and ‘cover up’ across different specialties. University Hospitals of Morecambe Bay Foundation Trust, which spent 18 months in special measures midway through the last decade, is again now the subject of significant regulatory intervention from NHS England. The regulator has appointed Simon Bennett as a board-level improvement director, which comes after he undertook a similar assignment at the struggling Stockport FT. It comes amid ongoing external investigations into the trust’s urology and trauma and orthopaedics specialties, where serious allegations have been made about attempts to cover up poor care. The trust has a troubled history of care failings and regulatory intervention, including a major maternity scandal which culminated in the Kirkup Inquiry in the first half of the 2010s, and being placed in special measures in 2014. It was widely recognised that positive progress was subsequently made to implement the inquiry recommendations and improve services, which culminated in the trust exiting special measures in late 2015, and being rated “good” by the CQC in early 2017. However, the recent allegations and investigations have again brought regulatory intervention. Read full story (paywalled) Source: HSJ, 20 April 2021
  12. News Article
    An NHS trust has admitted failing to provide safe care and treatment for a mother and her baby boy, who died seven days after an emergency delivery. Mother Sarah Richford said it brought "some level of justice" for baby Harry's death in 2017. Lawyers for the East Kent Hospitals Trust pleaded guilty to the charge at Folkestone Magistrates Court. The trust said it had made "significant changes" and would "do everything we can to learn from this tragedy". Mrs Richford said: "Although Harry's life was short, hopefully it's made a difference and that other babies won't die". She added: "If somebody had done this before Harry was born he may be alive today." The prosecution by the Care Quality Commission followed an inquest in 2020, which found Harry's death was wholly avoidable and contributed to by neglect at Margate's Queen Elizabeth the Queen Mother Hospital. The inquest found more than a dozen areas of concern in the care of Harry and his mother, including failings in the way an "inexperienced" doctor carried out the delivery, followed by delays in resuscitation. Coroner Christopher Sutton-Mattocks criticised the trust for initially saying the death was "expected", adding that an inquest was only ordered due to the family's persistence. Read full story Source: BBC News, 19 April 2021
  13. News Article
    Seven individuals face prosecution for alleged ill-treatment and wilful neglect of patients at a hospital for people with severe learning disabilities. The alleged offences took place at the psychiatric intensive care unit at Muckamore Abbey Hospital in County Antrim, Northern Ireland. Prosecution follows ongoing police inquiries A police investigation into claims of abuse at the hospital has been ongoing since 2018, following reports of inappropriate behaviour and alleged physical abuse of service users by staff. Read full story Source: Nursing Standard, 19 April 2021
  14. News Article
    A nurse of the year finalist who faced being struck off after she saved a woman's life has been cleared by an official inquiry, the Mail can reveal. Leona Harris, 48, who gave a blood transfusion in a speeding ambulance to a woman who was haemorrhaging after losing her baby, has faced a four-year nightmare, including the potential loss of her 24-year career and home to pay legal costs. Through no fault of Mrs Harris's, the required prescription for the use of the blood had not been taken on to the ambulance with the patient. Now, four years on, the Nursing and Midwifery Council (NMC) has concluded Mrs Harris 'undoubtedly acted in the best interests of the patient' and has 'no case to answer'. The ruling raises major concerns about the conduct of the East Lancashire Hospitals Trust, which used inexplicably altered statements about Mrs Harris's conduct. The 600-page report will heap new pressure on Health Secretary Matt Hancock, who pledged that 'eradicating the curse' of NHS bullying would be one of his 'top priorities'. Read full story Source: Mail Online, 20 April 2021
  15. News Article
    The Labour Party will call on the government to commit to a target of ending the Black maternal mortality gap during a landmark debate about the topic later on Monday. This comes as shocking figures show Black women are over four times more likely than white women to die during or after pregnancy or childbirth in the UK. MPs will debate a petition relating to Black maternal healthcare and mortality. Scheduled to take place at 6.15pm this evening, the session will be led by Petitions Committee Chair Catherine McKinnell MP. Read full story Source: The Independent, 19 April 2021
  16. News Article
    Pregnant women should be offered a Covid jab when other people their age get one, the UK's vaccine advisers say. They say the Pfizer and Moderna vaccines are preferable because data from the US in 90,000 pregnant women has not raised any safety concerns. Up until now, only women with underlying health conditions or those whose risk of exposure to the virus was high were eligible. The shift in advice brings the UK into line with other countries. The Joint Committee on Vaccination and Immunisation now advises that pregnant women should all be offered the Pfizer-BioNTech or Moderna vaccines where available, at the same time as the rest of the population. They are encouraged to discuss the risks and benefits of the vaccines with their doctor before making the appointment, but it is not a requirement. "There is no evidence to suggest that other vaccines are unsafe for pregnant women, but more research is needed," it added. Currently, there is a lack of data on the AstraZeneca vaccine in pregnancy because pregnant women were not included in trials, but the JCVI says more evidence may be forthcoming in the near future. Read full story Source: BBC News, 17 April 2021
  17. News Article
    Sarah Spoor and her two adult sons have spent the past 14 months shielding in a one-bedroom apartment, with no garden, in west London. Her youngest sleeps in the bedroom, his brother has a pull-out bed in the kitchen, while Spoor takes the living room in another fold-out bed. All three have complex medical conditions that leave them vulnerable to Covid, and despite the strain of living in such close quarters, they don’t feel safe leaving home any time soon. “If we catch it, we die; it’s that simple. In the 14 months, I have probably been out about four times, and that’s usually in some dire emergency,” said Spoor, who provides round-the-clock care for her sons, 20 and 24, after their medical team decided it was too risky for their usual carers to continue visiting. The family has yet to be vaccinated as their medical conditions, which include type 1 diabetes, adrenal insufficiency, pernicious anemia and thyroid failure, mean they are likely to experience a severe reaction leading to hospital admission, and they are concerned about the risk of catching Covid in hospital when cases are still prevalent. Spoor is not alone in fearing a return to life after lockdown, with disability charity Scope estimating 75% of disabled people plan to continue shielding until after their second vaccine dose, and some for longer. “I think there is a potential long-term impact that groups of people become squirrelled away and it’s potentially easy for governments and local authorities to forget about them,” said James Taylor, executive director of strategy and social change at Scope. “We’re really worried that, in the long-term, lots of the rights that disabled people have fought for, the visibility, the recognition of disabled people as equal, that all falling away and going backwards.” Read full story Source: The Guardian, 19 April 2021
  18. News Article
    As a teenager, Kelly Moran was incredibly sporty: she loved to run and went to dancing lessons four times a week. But by the time she hit 29, she could barely walk or even drive, no longer able to do all the activities she once enjoyed. She had pain radiating into her legs. Her pain was repeatedly dismissed by doctors, who told her it was in her head. She moved back to her parents’ house in Manchester and left her job. She decided to seek treatment privately and was told she had endometriosis. Soon, with the right treatment, her life improved. Kelly is among dozens of women who got in touch to share their stories with the Guardian on the topic of women’s pain. Women are almost twice as likely to be prescribed powerful and potentially addictive opiate painkillers than men, a Guardian analysis shows. Data from the NHS Business Services Authority, which deals with prescription services in England, shows a large disparity in the number of women being given these drugs compared with men, with 761,641 women receiving painkiller prescriptions compared with 443,414 men, or 1.7 times, and the pattern is similar across broad age categories. The women who reached out said they felt that they were often “fobbed off” with painkillers when their problems required medical investigation. Read full story Source: The Guardian, 16 February 2021
  19. News Article
    Public services are dismissing sickle cell patients because the illness disproportionately affects Black people, campaigners have warned. The blood disorder is prevalent among African and Caribbean communities and advocacy groups say this means it remains poorly understood within state institutions, often leading to the needless suffering and even death of those diagnosed. The issue has gained wider attention following the high-profile cases of two Black men, Richard Okorogheye and Evan Nathan Smith, who lived with the disease and died amid claims their vulnerabilities were overlooked by the NHS and police. Chris Abdullahi, co-founder of charitable initiative Sound of Sickle, told The Independent it is common for sickle cell patients’ painful symptoms to be ignored by healthcare practitioners. He said he has heard similar accounts “well over 100 times” from across the UK. “Just last week someone else mentioned that they were in hospital and had to battle their nurses for pain medication from opioids to something as simple as ibuprofen,” the 27-year-old, who also lives with sickle cell, said. These experiences serve to further entrench the “massive sense of distrust” in the healthcare system which is evidenced through lower vaccine uptake in Black communities, Mr Abdullahi explained. A lack of awareness about the disease has led sickle cell patients to often form informal support networks, through which information can be exchanged about the best hospitals at which to maximise the chances of their condition being taken seriously. Read full story Source: The Independent, 18 April 2021
  20. Content Article
    Video series catching up with alumni of the Darzi Fellowship in Clinical Leadership to find out what are they up to, how they got there, and how the Fellowship has influenced their work in the NHS and wider health and care landscape. In this episode, Jamie Stafford, Senior Programme Manager with the Community Mental Health Transformation Programme for East London Foundation Trust (ELFT) talks about how frustration with the system lead him to the Darzi Fellowship, and how his Fellowship Year taught him the value of nurturing cross-boundary relationships to create a better experience of care.
  21. Content Article
    The NHS Staff Survey for England reported that almost a quarter of all NHS staff experienced harassment, bullying or abuse from colleagues in the last 12 months. Not only does this have a devastating impact on individuals and the teams within which they work, but it can have dire consequences for patient care. The Royal College of Surgeons of Edinburgh is committed to eradicating bullying and undermining from the surgical and dental professions. It has a number of resources on its website.
  22. News Article
    The NHS in England is required by legislation to ensure that at least 92 per cent of patients on the waiting list have been waiting no longer than 18 weeks from referral to treatment. At the end of February, following a year of covid restrictions, that waiting time measure exceeded 52 weeks. How much longer than 52 weeks? We don’t know, because the data stops at “52 plus”. But there is good news, because this is about to change. Guidance was issued during March requiring two major improvements to the published RTT data. Firstly, instead of stopping at 52 weeks plus, the weekly waiting time cohorts will continue up to 104 weeks plus. Secondly, we are going to get a lot more information about mental health and other RTT waiting times, because the catch-all “Other” specialty is going to be broken down into medical, surgical, mental health, paediatric and the rest. Read full story (paywalled) Source: HSJ, 16 April 2021
  23. News Article
    WHO/Europe and the Hellenic Republic of Greece today open a new sub-office in the country focusing on quality of care and patient safety. Acting as a centre of excellence, the sub-office will work towards achieving the highest level of well-being, health and health protection in the WHO European Region, in line with the Sustainable Development Goals (SDGs). Speaking at its opening, WHO Regional Director for Europe Dr Hans Henri P. Kluge said, “Better quality of care relies on a strong primary health care system, where most preventive activities, diagnostics, consultations and treatments occur. Let us make no mistake – the quality of care encompasses all levels of a health system, hence the need to integrate quality policies across the board.” Read full story Source: WHO, 15 April 2021
  24. Event
    Dr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by Thankam Gomez, Founder & CEO, Cygnia Healthcare, Mark Graban, Author of "Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement”, Management Consultant, Coach, Professional Speaker, Podcaster, Senior Advisor to KaiNexus, and Beth Beswick, Retired Vice President, Human Resources, Carteret Healthcare to discuss the background of accountability in healthcare, the history of healthcare culture, and the current organisational barriers to implementing an environment of shared learning. Additionally, panelists will discuss stepwise recommendations for the implementation of a Just Culture and will propose strategies for evaluating the impact of the shift from a blaming culture to a systems analysis approach. Register
  25. News Article
    Hundreds of senior NHS managers have voiced their fears for the future of the health service amid the ongoing coronavirus crisis without a significant pay rise to help retain staff on the frontline. A survey of more than 800 senior NHS managers has revealed the extreme pressure some have been working under, with many working 20 or more hours of unpaid extra hours each week. More than 90 per cent backed a significant pay rise for NHS staff to try and head off a feared exodus of nurses, doctors and other staff leaving the NHS after the pandemic. This would help shore up the service as it faces the daunting task of tackling record waiting lists now totalling 4.7 million patients. Some managers said that the government’s planned 1 per cent pay rise was an “insult” and made them feel “worthless”, in responses to the survey, run by the Managers in Partnership union. Another described NHS staff as being treated like “cannon fodder” during the crisis. Read full story Source: The Independent, 16 April 2021
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