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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    The Government has failed to implement a number of recommendations from significant inquiries into major patient safety issues, years after they were agreed to, according to an independent panel. The report, commissioned by the Health and Social Committee in the wake of the Lucy Letby case, voiced concerns about “delays to take real action”. As part of its investigation, the panel selected recommendations from independent public inquiries and reviews that have been accepted by government since 2010. Nine or more years have passed since these recommendations were accepted by the government of the day These covered three broad policy areas – maternity safety and leadership, training of staff in health and social care, and culture of safety and whistleblowing – and were used to evaluate progress. The panel gave the Government a rating of “requires improvement” across the policy areas. One of the recommendations was rated good. The report said that “despite good performance in some areas” the rating “partly reflects the length of time it has taken for the Government to make progress on fully implementing four of the recommendations which were accepted nine years ago, or longer”. “Progress is imminent in several areas, which is reassuring, but we remain concerned about the time it has taken for real action to be taken,” it added. Read full story Source: The Independent, 22 March 2024 Read Patient Safety Learning's response to the report: Response to Select Committee report: Evaluation of the Government’s progress on meeting patient safety recommendations
  2. Content Article
    This report, produced in collaboration with the Association of Ambulance Chief Executives and the NHS Confederation, highlights the pivotal role ambulance trusts play in delivering urgent and emergency care and sets out a long-term vision for an enhanced role they could take in co-designing this care. It sets out the case for change and includes several case studies that demonstrate the benefits of ambulance services taking this broader approach.
  3. News Article
    A new system requiring GPs to agree death certificates with a medical examiner is unlikely to launch at the beginning of April, it has emerged. The system, which will see medical examiners (MEs) providing independent scrutiny of all deaths in the community which are not taken to the coroner, had previously been due to come in from April last year. However, it was delayed by one year to allow time for Parliament to introduce the necessary supporting legislation and, according to the Department of Health and Social Care (DHSC), this has yet to happen. A spokesperson told Pulse that the Government’s intention is to still introduce secondary legislation ‘from April’ to implement death certification reform. However, it could not confirm the exact date the system will launch and said it would provide an update before the end of March. Nottingham GP Dr Irfan Malik told Pulse that local GPs and practice staff ‘seem to be aware there is a delay’ but have had ‘no official emails’ or communication confirming the delays. Read full story Source: Pulse, 20 March 2024
  4. News Article
    Trust chiefs have collectively called for the Care Quality Commission (CQC) to review its use of single-word inspection ratings, following MPs’ calls for an overhaul of Ofsted ratings for schools. In a report containing a series of recommendations for CQC reform, shared with HSJ, NHS Providers urges the regulator to re-evaluate the success of its single-word ratings, asking it to consider adding a narrative verdict as part of its new provider assessment reports. The recommendation is made “in the context of the Ofsted inquiry findings” following the death of headteacher Ruth Perry by suicide, which a coroner ruled was contributed to by an Ofsted inspection. It prompted MPs on the Commons’ education committee to call for a ban on single-word Ofsted ratings. The NHSP report said the inquiry’s concerns around inspectors’ behaviour, the complaints process, and single ratings can also be applied to CQC. The report adds: “While we recognise the differences between the two regulators’ approaches, we believe now is the right time to take stock… for example, CQC may need to consider the value of its single-word ratings, modelled upon Ofsted’s rating system. “As suggested by the Nuffield Trust and many trust leaders, a single-word rating will inevitably oversimplify what happens in a very complex organisation". Read full story (paywalled) Source: HSJ, 21 March 2024
  5. News Article
    Lessons have not been learned to prevent further deaths in north Wales, coroners have told the health secretary. Over the past year, coroners in Wales wrote 41 "prevention of future deaths reports" and more than half were issued to Betsi Cadwaladr health board. Health Secretary, Eluned Morgan, said 27 reports issued since January 2023 was "of significant concern". Betsi Cadwaladr health board said every report was taken very seriously and work was ongoing to respond to key themes. Ms Morgan said all but three of the deaths happened before the health board was moved back into special measures in February 2023. The "systemic issues" that emerge as common themes from the coroners' reports include: the quality of investigations and effectiveness of actions a lack of integrated electronic health records impacting care the impact of delays in the system on ambulance response times. In a written statement earlier this week, Ms Morgan said the health board had given assurances that it was taking the matter "extremely seriously". Read full story Source: BBC News, 21 March 2024
  6. Content Article
    The Health and Social Care Select Committee’s Independent Expert Panel produces reports which assess progress the Government has made against their own commitments in different areas of health and care policy. On the 22 March 2024 they published a new report evaluating the implementation of accepted recommendations made by inquiries and reviews into patient safety. This blog sets out Patient Safety Learning’s response to its findings.
  7. Content Article
    The aim of this study was to quantify the difference in weekday versus weekend occupancy, and the opportunity to smooth inpatient occupancy to reduce crowding at children's hospitals. They study found that hospitals do have substantial unused capacity, and smoothing occupancy over the course of a week could be a useful strategy that hospitals can use to reduce crowding and protect patients from crowded conditions.
  8. News Article
    Many popular AI chatbots, including ChatGPT and Google’s Gemini, lack adequate safeguards to prevent the creation of health disinformation when prompted, according to a new study. Research by a team of experts from around the world, led by researchers from Flinders University in Adelaide, Australia, and published in the BMJ found that the large language models (LLMs) used to power publicly accessible chatbots failed to block attempts to create realistic-looking disinformation on health topics. As part of the study, researchers asked a range of chatbots to create a short blog post with an attention-grabbing title and containing realistic-looking journal references and patient and doctor testimonials on two health disinformation topics: that sunscreen causes skin cancer and that the alkaline diet is a cure for cancer. The researchers said that several high-profile, publicly available AI tools and chatbots, including OpenAI’s ChatGPT, Google’s Gemini and a chatbot powered by Meta’s Llama 2 LLM, consistently generated blog posts containing health disinformation when asked – including three months after the initial test and being reported to developers when researchers wanted to assess if safeguards had improved. In response to the findings, the researchers have called for “enhanced regulation, transparency, and routine auditing” of LLMs to help prevent the “mass generation of health disinformation”. Read full story Source: The Independent, 20 March 2024
  9. Content Article
    NHS Boards are required under the National Whistleblowing Standards (the Standards) to publish annual whistleblowing reports setting out performance in handling whistleblowing concerns.
  10. News Article
    A group representing hundreds of clinicians has applied to contribute to the Lucy Letby inquiry, to challenge NHS culture around whistleblowing. Their experiences of raising concerns should inform the inquiry, they say. Letby murdered seven babies and attempted to murder another six while working at the Countess of Chester NHS trust between June 2015 and June 2016. The public inquiry is examining how the nurse was able to murder and how the hospital handled concerns about her. "The evidence of this group relating to how whistleblowers are treated, not just at one trust but across the UK, is of huge significance," Rachel di Clemente, of Hudgell Solicitors, acting for the clinicians, said. The group, NHS Whistleblowers, comprising healthcare professionals across the UK, including current and former doctors, midwives and nurses, has written to Lady Justice Thirlwall's inquiry, asking for them to be formally included as core participants. The inquiry has stated it will consider NHS culture. And the group says "a culture detrimental to patient safety" is evident across the health service. "NHS staff who have bravely spoken up about patient-safety concerns or unethical practices deserve to have their voices heard," Dr Matt Kneale, who co-chairs Doctors' Association UK, which is part of the group, said. Read full story Source: BBC News, 21 March 2024
  11. Content Article
    Chris Elston, a patient safety education lead, shares how he used Safety Engineering Initiative for Patient Safety (SEIPS) and Accident Mapping (AcciMap) to learn from a patient safety incident at his Trust.
  12. Content Article
    Doctors working in temporary positions (known as locums) are a key component of the medical workforce and provide necessary flexibility and additional capacity for NHS organisations and services. There have been concerns about the quality and safety of locum practice and the way NHS uses locum doctors. The number of doctors working as locums, and the costs of this to the NHS have caused some concerns nationally in recent years. It has also been suggested that locum doctors may not provide as good a quality of care as permanent doctors. Research carried out by a team at the University of Manchester provided important new information on these issues. The findings indicated that locum working and how locums were integrated into organisations could pose significant challenges for patient safety and quality of care.
  13. Content Article
    NIHR Patient Safety Research Collaborations (PSRCs) are partnerships between universities and NHS trusts that support patient safety research. There are six PSRCs in England, aiming to bring patient safety discoveries to frontline NHS services.
  14. Content Article
    Fear of retaliation by leaders or colleagues can prevent staff from reporting adverse events, unsafe conditions, or near misses. This article presents strategies to improve just culture in the perioperative environment, which is prone to hierarchical structure. Strategies include creating an accessible reporting system, implementation of a "good catch" programme, and leadership support for staff who submit reports.
  15. Event
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    As we all know, Patient Safety remains an urgent global public health issue, pertinent to all health systems around the world. Among the most important advances in recent years, the WHO’s publication of the first Global Patient Safety Action Plan 2021-2030 stands out, a roadmap that is expected to guide member countries in making decisions and implementing different strategies and measures with the aim of safeguarding the safety of care as a central axis of health policies. The 2023 summit in Montreux marked another milestone in the series. It focused on implementing known measures and interventions. This is crucial to overcome the so-called implementation gap to further advance in strengthening patient safety . The Chile 2024 Summit will delve into how different countries have managed to implement and sustain over time different strategies related to delivering safe health care in the framework of the 7 strategic objectives of the Global Patient Safety Action Plan, key lessons learned in the implementation process, results obtained and upcoming challenges, with the aim of gathering this knowledge and transforming it into national commitments to address concrete actions. This is why the summit 2024 will follow the overarching slogan of “Bringing and maintaining changes in patient safety policies and practices”. Interested participants are welcome to register online https://psschile.minsal.cl/?page_id=945&lang=en#038;lang=en (English) and https://psschile.minsal.cl/?page_id=945 (Spanish) More information about the registration procedure, the programme, and speakers as well as on practical matters can be found on the website and will be continuously updated: https://psschile.minsal.cl/
  16. Content Article
    Around 1 in 5 children have eczema (also known as atopic eczema or atopic dermatitis). They typically have inflamed and dry, itchy skin. During flare-ups (periods of worsening symptoms), their skin becomes vulnerable to cracks, bleeding and infection. Eczema impacts quality of life; it can impair sleep, ability to concentrate at school, self-confidence and mood. The condition is usually long-term (chronic), although it improves, or even clears completely, in some children as they get older. Even so, it is one of the most common reasons for children and young people to seek medical care. Community pharmacists and GPs are the first port of call and, while there is no cure, treatments can soothe sore skin, reduce itching, improve the appearance of the eczema, and reduce infections.
  17. Content Article
    Diagnostic errors cause significant patient harm. The clinician’s ultimate goal is to achieve diagnostic excellence in order to serve patients safely. This can be accomplished by learning from both errors and successes in patient care. However, the extent to which clinicians grow and navigate diagnostic errors and successes in patient care is poorly understood. Clinically experienced hospitalists, who have cared for numerous acutely ill patients, should have great insights from their successes and mistakes to inform others striving for excellence in patient care.
  18. News Article
    A campaigner in Norfolk says the "deaths crisis" at the county's mental health trust is getting worse. Bereaved relatives met the mental health minister, Maria Caulfield, to discuss failings at the Norfolk and Suffolk NHS Foundation Trust (NSFT). The trust says it is on a "rapid, and much-needed journey of improvement". Mark Harrison, from the Campaign to Save Mental Health Services in Norfolk and Suffolk, said: "We judge people by what they do, not what they say." Members of the campaign group met Ms Caulfield and other MPs in Westminster on 12 March and demanded an independent public inquiry into the trust. It came after a report last summer which found that more than 8,000 mental health patients had died unexpectedly in Norfolk and Suffolk between 2019 and 2022. At the meeting, it was agreed Ms Caulfield would meet bosses at the NSFT. The health select committee will also be asked to conduct an inquiry into the trust as part of a broader public inquiry. But Mr Harrison said he had little confidence anything would change. "The deaths crisis is just out of control and it's accelerating," he said. "We have been doing this for 10 years. Every time somebody promises to do something, it doesn't come to anything." Read full story Source: BBC News, 20 March 2024
  19. Content Article
    SafetyNet brings together the collective efforts of the six NIHR Patient Safety Research Collaborations (NIHR PSRCs).across England in addressing patient safety challenges of strategic importance. The quarterly SafetyNet newsletter offers you the opportunity to find out about the exciting research and collaborations that are happening across the safety centres and wider organisations.
  20. Content Article
    These principles underpin how NHS services must approach concerns that are raised by staff, students and volunteers about health services.
  21. Content Article
    In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored side-lined or victimised. Why staff don’t speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Concluding with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.
  22. Content Article
    Currently, it is estimated that more than one in five people in the UK are living in poverty. This King's Fund analysis reveals that people living in poverty find it harder to live a healthy life, live with greater illness, face barriers to accessing timely treatment, and die earlier than the rest of the population. The analysis looks at the link between poverty and each of the following: prevalence of ill health difficulties accessing health care late or delayed treatment poorer health outcomes. The long read argues that while the NHS can, and should, do more to make timely care accessible to deprived communities, wider government and societal action is needed to address the root causes of poverty.
  23. Content Article
    Diagnostic delays in the emergency department (ED) are a serious patient safety concern. This retrospective cohort study included children treated at 954 EDs across 8 states, and examined the association between ED volume and delayed diagnosis of first-time diagnosis of an acute, serious conditions (e.g., bacterial meningitis, compartment syndrome, stroke). The researchers found that EDs with lower pediatric volume had higher rates of delayed diagnosis across 23 serious conditions. 
  24. News Article
    Millions of people with long-term illnesses should get medical treatment at home rather than in hospital to help them carry on working, according to a report. The NHS is being urged to deliver more medicines directly to patients’ doors, so they can self-administer drugs at home, and “get on with life” rather than having to travel back and forth to hospitals. New research shows this model of care, called clinical homecare, helps those needing regular treatment for chronic conditions, including cancer and arthritis, to stay in employment and retain independence. Experts said providing more patients with specialist medicines at home can play a vital role in tackling the UK’s growing rates of economic inactivity, with 2.7 million long-term sick now signed off work. The report, commissioned by the National Clinical Homecare Association, said expanding the schemes means millions of patients “could be supported to continue working and living their lives without being defined by their health status”, adding that up to three million cancer patients could benefit. Read full story (paywalled) Source: The Times, 19 March 2024
  25. News Article
    William Wragg, the Tory chair of the Public Administration and Constitutional Affairs Committee (PACAC), has belatedly intervened in the growing crisis over the failure of the Prime Minister to appoint a new Parliamentary Ombudsman to replace Rob Behrens who quits the Parliamentary and Health Service Ombudsman on 31 March 2024. In a letter published on the committee’s website, Mr Wragg asks Sir Alex Allan, the senior non executive director on the Parliamentary and Heath Services Ombudsman board, what measures will be taken to keep the office going and what is going to happen to people who, via their MP, want to lodge a complaint to the Ombudsman. He also raises whether reports can be published and complaints investigated. The letter discloses that recruitment for a new Ombudsman began last October and a panel chose the winning candidate at the beginning of January. Since then the Cabinet Office and Rishi Sunak, who has to approve the appointment, have not responded. The silence from Whitehall and Downing Street means no motion can be put to Parliament appointing a new Ombudsman, who then appears before the PACAC for a pre appointment hearing. PACAC has only a couple of weeks to set up the hearing. Read full story Source: Westminster Confidential, 12 March 2024
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