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Patient Safety Learning

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  1. Content Article
    This report is a culmination of findings from Rare Disease UK and Genetic Alliance UK to evidence the experiences of those living with a rare condition. The report underpins their call for a refresh and review of the UK Strategy for Rare Diseases focussing on five key areas: diagnosis, rare disease care and treatment, information and support, rare disease research and keeping the strategy up to date.
  2. Content Article
    The coronavirus has caused significant disruption to NHS services, which may have been particularly felt by those with a long-term condition. Rachel Hutchings takes a closer look at what it’s been like for people living with heart disease, and stresses the importance of understanding patients’ experiences as we head towards winter with a second wave underway.
  3. Content Article
    The story of Pat Denton who died from a surgery site infection after surgery.
  4. Content Article
    Coronavirus may leave patients with a condition called POTS that makes the heart rate soar after even the mildest activities. Shannon Gulliver Caspersen is a physician in the US who contracted what was initially a fairly mild case of COVID-19 in early March. Seven months later, she remains substantially debilitated, with profound exhaustion and a heart rate that goes into the stratosphere with even the tiniest bits of exertion, such as pouring a bowl of cereal or making a bed. In this article in the New York Times, Shannon discusses her experience of long covid and her diagnosis of postural orthostatic tachycardia syndrome (POTS) and her concerns on how much disability we will accumulate by the end of this pandemic.
  5. Content Article
    Dr Henrietta Hughes speaks to HSJ on making the fear of retribution a thing of the past and speaking up business as usual in the NHS.
  6. Content Article
    Dr John Campbell, a retired A&E nurse, discusses the research and evidence on the long-term health consequences of COVID-19 in this video.
  7. Content Article
    The involvement of patients in decisions about their care is essential to help effectively manage long-term conditions and help achieve the best possible patient outcome. ‘Shared decision making’ ensures that individuals are supported, by their healthcare partners, to make decisions about their care or treatment, that are right for them. Shared decision making is included in the NHS Constitution, and AbbVie, a research-driven biopharmaceutical company. hopes to help continue raising the profile of patient involvement. AbbVie wants to see shared decision making be widely adopted across NHS services. To support this ambition, AbbVie held the Shared Decision Making Showcase in Parliament on the 10 March 2020. A year on from the publication of the NHS Long Term Plan, and Universalised Personalised Care Plan – which established ambitious targets to put shared decision making at the heart of patient care – the showcase provided a platform for patient groups, NHS Trusts, and healthcare providers to share their innovative work. The projects showcased ranged from MS, arthritis, Lymphoma, Autism, Hepatitis C, kidney dialysis and more—all focused on empowering patients to take an active part in decisions about their treatment and care. AbbVie has supported a number of organisations and projects to develop and enable shared decision making including two of the showcased initiatives: a survey of treatment decision experience amongst psoriasis patients and the work of the Patient Information Forum to develop and implement the Perfect Patient Information Journey.
  8. Content Article
    This article explains what herd immunity is and what the World Health Organization (WHO)'s position is on herd immunity as a way of fighting COVID-19.
  9. Content Article
    Miranda Davies considers the difficult issue of the NHS's ability to get hold of basic drugs for patients who need them - and how the pandemic may be affecting this.
  10. Content Article
    Asaf Bitton, is Executive Director of Ariadne Labs and a global expert on primary care policy and delivery. In this interview with the Institute for Healthcare Improvement (IHI), Bitton talks about both the losses and the opportunities presented by COVID-19 and the rapid expansion of telehealth. 
  11. News Article
    Women aged 50-60 are at greatest risk of developing “long Covid”, analysis suggests. Older age and experiencing five or more symptoms within the first week of illness were also associated with a heightened risk of lasting health problems. The study, led by Dr Claire Steves and Prof Tim Spector at King’s College London, analysed data from 4,182 COVID Symptom Study app users who had been consistently logging their health and had tested positive for the virus. In general, women were twice as likely to suffer from Covid symptoms that lasted longer than a month, compared with men – but only until around the age of 60, when their risk level became more similar. Covid vaccine tracker: when will a cor Increasing age was also associated with a heightened risk of long Covid, with about 22% of people aged over 70 suffering for four weeks or more, compared with 10% of people aged between 18 and 49. For women in the 50-60 age bracket, these two risk factors appeared to combine: They were eight times more likely to experience lasting symptoms of Covid-19 compared with 18- to 30-year-olds. However, the greatest difference between men and women was seen among those aged between 40 and 50, where women’s risk of developing long Covid was double that of men’s. “This is a similar pattern to what you see in autoimmune diseases,” said Spector. “Things like rheumatoid arthritis, thyroid disease and lupus are two to three times more common in women until just before menopause, and then it becomes more similar.” His guess is that gender differences in the way the immune system responds to coronavirus may account for this difference." Read full story Source: The Guardian, 21 September 2020
  12. Event
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    NCRI Virtual Showcase will feature a number of topical sessions, panel discussions and proffered paper presentations covering the latest discoveries across: Big data and AI Prevention and early detection Immunology and immunotherapy Living with and beyond cancer Cancer research and COVID-19 Further information and registration
  13. News Article
    A major acute trust has confirmed the health service inspectorate has begun a criminal investigation into three incidents at its hospitals. University Hospitals Birmingham FT told HSJ the Care Quality Commission (CQC) has started a criminal investigation into incidents involving potential errors around the provision of anti-coagulant medication. The trust received a letter from the CQC this month informing it that the regulator has begun the investigation under regulation 22 of the Health and Social Care Act 2008 (regulated activities) regulations 2014. The incidents happened at Queen Elizabeth Hospital in Birmingham and Good Hope Hospital — the trust’s two main sites. Regulation 22 says: “In order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity.” The CQC launched a prosecution into East Kent Hospitals University FT this month for failing to meet fundamental standards of care. The regulator also successfully prosecuted University Hospitals Plymouth Trust in September after it pleaded guilty to breaching the duty of candour. Read full story (paywalled) Source: HSJ, 23 October 2020
  14. Content Article
    Black, Latinx, and Native Americans are experiencing disproportionate burdens of infections, hospitalisations, and deaths from COVID-19. Similar disparities are observed in other countries where minority groups face hurdles in accessing health, education, and social services as well as affordable, healthy food. These stark manifestations of health inequities have emerged in the wake of a body of evidence linking obesity and obesity-related chronic diseases, such as hypertension, diabetes, and cardiovascular disease — conditions that disproportionately affect disadvantaged populations — with severe outcomes from COVID-19. Though the factors underlying racial and ethnic disparities in COVID-19 in the United States are multifaceted and complex, long-standing disparities in nutrition and obesity play a crucial role in the health inequities unfolding during the pandemic.
  15. News Article
    A mental health unit where a patient was found dead has been placed into special measures over concerns about safety and cleanliness. Field House, in Alfreton, Derbyshire, was rated "inadequate" by the Care Quality Commission (CQC) following a visit in August. A patient died "following use of a ligature" shortly after its inspection, the CQC said. Elysium, which runs the unit for women, said it was "swiftly" making changes. The inspectors' verdict comes after the unit was ordered to make improvements, in January 2019. Dr Kevin Cleary, the CQC's mental health lead, said: "There were issues with observation of patients, a lack of cleanliness at the service and with staffing. "There were insufficient nursing staff and they did not have the skills and experience to keep patients safe from avoidable harm. Bank and agency staff were not always familiar with the observation policy." "It was also worrying that not all staff received a COVID-19 risk assessment, infection control standards were poor, and hand sanitiser was not available in the service's apartments." The CQC said a follow-up inspection on Monday had showed "areas of improvement" but it would continue to monitor the service. Read full story Source: BBC News, 22 October 2020
  16. Content Article
    The past several months have shown that most people hospitalized with COVID-19 will get better. As inspiring as it is to see these patients breathe on their own and converse with their loved ones again, we are learning that many will leave the hospital still quite ill and in need of further care. But little has been published to offer a detailed demographic picture of those being discharged from our nation’s hospitals and the types of community-based care and monitoring that will be needed to keep them on the road to recovery. Dr. Francis Collins takes a look at the current research.
  17. Content Article
    Patient Safety Movement's Dr Donna Prosser, CCO, and Dr Edward Kelley, Director of Integrated Health Services Department at World Health Organization (WHO) Headquarters, Geneva, give a COVID-19 update in this video. Topics discussed include the current climate of the COVID-19 pandemic broken down by region, influenza season amidst COVID-19, the reopening of schools across the globe, and Dr Kelley's speculations on how we will be able to overcome this crisis in the upcoming future.
  18. Event
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    How can we better support nurses and midwives to flourish and thrive in their work? Join the King's Fund at this free online event to discuss the changes needed to empower nurses and midwives to shape and provide the compassionate, high-quality care that they aspire to in a sustainable way – through the COVID-19 pandemic and beyond. The conversation will explore: workplace stressors, work conditions and ways of working – including workload, shift patterns and supervision – that have an impact on nurse and midwife wellbeing, and how these can be positively transformed organisational cultures and leadership styles – including those around diversity and inclusion, psychological safety and compassionate leadership at all levels – that need to be cultivated, and how progress can be achieved lessons and examples of good practice from across the health and care system, from both before and during the COVID-19 pandemic. Register
  19. Event
    2020 has undoubtedly played a key role in forcing NHS organisations to sit up and take note of the productivity increases and money-saving benefits that digital tools and tech can have, this event aims to share some core policy updates and best practice from across the UK. This fully immersive Securing Secondary Care Excellence: The Virtual Acute Technology Conference platform will allow you to listen, learn and engage with some key policy-shaping guest speakers, network with peers from across the NHS and meet some of the UK’s most forward-thinking and innovative commercial problem solvers. Register
  20. Event
    Data and Information have been and continues to be a crucial and integral part of the health services fight against COVID-19. Data and patient information are constantly being used in new ways to help to care for people and help the NHS and social care to better understand and respond to the virus. NHS England along with NHSX are currently using data as evidence to help shape new care models and keep the public safe from the COVID-19 virus. The newly established NHS COVID-19 Data Store will provide a high-value tool for helping NHS monitor data sets and establish trends. This data can be used to look at several things such as bed capacity in hospitals or the number of ventilators available in a specific area. Our Developing new care models: The NHS Virtual Data & Information Congress will provide delegates with an interactive overview of this new Data Store and share best practices from across the UK. Key data-driven topics include; • Using health data responsibly and safely for research and innovation • Supporting vulnerable people (GP Records) • Remote patient monitoring • Security and regulation • Much more... Register
  21. Content Article
    Susan Warby, 57, was mistakenly given a glucose rather than a saline drip at West Suffolk Hospital after an operation for a perforated bowel in July 2018. Staff noticed a rise in blood sugar concentrations but gave her insulin to lower them rather than check the drip, which remained in place for 36 hours. In 2008 the National Patient Safety Agency made recommendations for safe arterial line management. In 2014 the Association of Anaesthetists published guidelines aimed specifically at preventing such events. Structured processes to prevent inadvertent use of a glucose-containing fluid to flush an arterial line and regular blood glucose sampling from a location other than the arterial line are only partial solutions. However, a survey of management of arterial lines undertaken in 2013 indicated that this was a common problem, that many of the NPSA recommendations were not widely implemented and that almost one third of respondents were aware of ‘wrong flush’ errors on their unit and a further third in other locations within their hospital. In this Rapid Response in the BMJ, Tim Cook says now is the time for patient representatives, clinicians, regulators and industry to work together to achieve widespread implementation of an engineered solution to prevent arterial line errors.
  22. Content Article
    In this blog, Patient Safety Learning sets out its response to NHS England and NHS Improvement’s draft Framework for involving patients in patient safety. We commend the intention and share thoughts on our perspective on this important patient safety issue. We make proposals for how to strengthen patient engagement and co-production.
  23. Content Article
    The Patient Information Forum ran a survey on covid choices. It asked how people are balancing the need to have new or ongoing health conditions treated and managed versus the risks of contracting COVID-19. The aim of the survey was to identify the factors important to patients’ decision-making. This will help charities and the NHS produce the information patients need to make crucial decisions about health and well-being.
  24. Content Article
    Michael Dowling is Northwell Health’s President and CEO and the Institute for Healthcare Improvement (IHI) Board Chair. In a new book, Leading through a pandemic: The inside story of humanity, innovation, and lessons learned during the COVID-19 crisis, Dowling describes how Northwell’s history of disaster preparedness was essential to their COVID-19 response. In the following interview with IHI, Dowling shares some sometimes surprising insights from an early epicenter of the pandemic.
  25. Content Article
    Guy's and St Thomas' has shared a downloadable version of the 'Big 5'.
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