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Patient Safety Learning

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  1. Content Article
    A lower recruitment and high turnover rate of registered nurses have resulted in a global shortage of nurses. In the UK, prior to the COVID-19 epidemic, nurses’ intention to leave rates were between 30 and 50% suggesting a high level of job dissatisfaction. In this study, published in BMC Nursing, Senek et al. analysed data from a cross-sectional mixed-methods survey developed by the Royal College of Nursing and administered to the nursing workforce across all four UK nations, to explore the levels of dissatisfaction and demoralisation – one of the predictors of nurses’ intention to leave.
  2. Content Article
    The NHS Staff Survey is one of the largest workforce surveys in the world and has been conducted every year since 2003. It asks NHS staff in England about their experiences of working for their respective NHS organisations. Follow the link below for further information and to complete the survey.
  3. Content Article
    Human factors is a scientific discipline which is used to understand the interacting elements and design of a complex system, aimed at improving system performance and optimising human well-being. This book brings together a range of specialist authors to explore some of the key concepts of human factors related to the field of paramedic practice. The system elements of paramedic practice can include the patient, the paramedic and their colleagues, the environment, the equipment, the tasks, and the processes and procedures of the organisation. The relationships between these components are explored in detail through chapters which cover ‘human error’, systems thinking, human-centred design, interaction with the patient, non-technical skills of individuals and teams, well-being of the paramedic, safety culture and learning from events. This helpful and informative guide provides frontline paramedics and ambulance clinicians with practical advice and knowledge of human factors that will be helpful in supporting safe and effective practice for all involved. It will also be of interest to pre-hospital care professionals who are involved in education, learning from events, procurement and influencing safety culture. Above all, it shows how an understanding and application of human factors principles can enhance system performance and well-being, and ultimately lead to safer patient care.
  4. News Article
    A further £8.7million is to be dished out to seven NHS hospital trusts to introduce digital records and e-prescribing. The money is part of a £78million investment which was announced in February 2018 and aims to accelerate the roll out of electronic prescribing systems across the NHS. The latest funding is part of the third wave of the investment, which will be handed out over three years. In 2018/ 19, £16.2 million was awarded, £29.4 million was given in 2019/20 and another £12 million will be invested later this year. The seven trusts which will benefit from this latest round of finding are: Portsmouth Hospitals NHS Trust (£1.7m) Solent NHS Trust (£988,000) Sussex Community NHS Foundation Trust (£637,000) United Lincolnshire Hospitals NHS Trust (£1.26m) North Cumbria Integrated Care NHS Trust (£2m) East Lancashire Hospitals NHS Trust (£1.6m) Birmingham Community NHS Trust (£531,000) National director of patient safety, Dr Aidan Fowler, said: “Patient safety is of paramount importance and is something we are continuously looking at ways to improve, whether through new technology, such as the introduction of electronic prescribing, or by building a safety culture where all NHS staff feel supported and safe to speak up.” Read full story Source: Digital Health, 1 October 2020
  5. News Article
    NHS Payouts linked to medication blunders have doubled in six years, fuelling record spending, official figures show. The NHS figures show that in 2019/20, the health service spent £24.3 million on negligence claims relating to medication errors - up from £12.8 million in 2013/14. The statistics show that in the past 15 years, almost £220 million has been spent on claims relating to the blunders. Previous research has suggested that medication errors may be killing up to 22,000 patients in England every year. Errors occur when patients are given the wrong drugs, doses which are too high or low, or medicines which cause dangerous reactions. In some cases, patients have been given medication which was intended for another person entirely, sometimes with fatal consequences. Other studies suggest that 1 in 12 prescriptions dispensed by the NHS involve a mistake in medication, dose or length of course. In some cases, patients have died after being given a dose of morphine ten times that which should have been administered, with other fatalities involving fatal reactions. Confusion often occurs when drugs are not labelled clearly, or when packaging of different medications looks similar. Jeremy Hunt, now chairman of the Commons Health and Social Care Committee, said the NHS needed to make far more progress preventing harms, instead of seeing an ever increasing negligence bill. He said: “It is nothing short of immoral that we often spend more cleaning up the mess of numerous tragedies in the courts, than we actually do on the doctors and nurses who could prevent them." Read full story (paywalled) Source: The Telegraph, 3 October 2020
  6. News Article
    Melissa Vanier, a 52-year-old postal worker from Vancouver, had just returned from holiday in Cuba when she fell seriously ill with COVID-19. “For the entire month of March I felt like I had broken glass in my throat,” she says, describing a range of symptoms that included fever, migraines, extreme fatigue, memory loss and brain fog. “I had to sleep on my stomach because otherwise it felt like someone was strangling me.” By the third week of March, Vanier had tested negative for Sars-CoV-2 – the virus that causes Covid-19. But although the virus had left her body, this would prove to be just the beginning of her problems. In May, she noticed from her Fitbit that her heart rate appeared to be highly abnormal. When cardiologists conducted a nuclear stress test – a diagnostic tool that measures the blood flow to the heart – it showed she had ischaemic heart disease, meaning that the heart was not getting sufficient blood and oxygen. Similar stories illustrate a wider trend – that the coronavirus can leave patients with lasting heart damage long after the initial symptoms have dissipated. Cardiologists are still trying to find out exactly why some people are left with enduring heart problems despite having had an apparently mild bout of COVID-19. The underlying mechanisms are thought to be slow and subtle changes that are quite different to those that put strain on the heart during the acute illness, especially in patients who have been hospitalised with the disease. Some cardiologists have suggested that treatments such as cholesterol-lowering drugs, aspirin or beta blockers may help patients with lingering cardiovascular effects many weeks or months after the initial infection, but the evidence remains limited. “It is too early to share data on this,” says Mitrani. “But these therapies have proven efficacy in other inflammatory heart muscle diseases. They have anti-inflammatory effects and we believe may help counter some of the lingering pro-inflammatory effects from Covid-19.” But for patients such as Vanier, there remains a long and uncertain road to see whether her heart does fully recover from the impact of the virus. “Psychologically this has been brutal,” she says. “I haven’t been back to work since I went on holiday in February. The heart hasn’t improved, and I now have to wait for more tests to see if they can find out more.” Read full story Source: The Guardian, 4 October 2020
  7. News Article
    Omnicell UK & Ireland, a leading provider of automated healthcare and medication adherence solutions, hosted a health summit on the eve of World Patient Safety Day, to discuss the impact of medication errors on patients and the NHS. The session focussed on the role technology can play in preventing such issues. The summit, this year held via webinar, comes off the backdrop of the Department of Health and Social Care disclosing that in England 237 million mistakes occur every year at some point in the medication process. These errors cause serious issues for patient safety, but also place a significant cost burden on an already stretched NHS. The 2019 Patient Safety Strategy published by NHS England and NHS Improvement also found the NHS failed to save 11,000 lives a year due to safety concerns with the cost of extra treatment needed following incidents being over £1bn. A number of high-profile panel members answered a series of questions from the audience on solutions and best practice to improve patient safety with the aim of debating and sharing ideas on how to meet challenges and the impact of COVID-19. One of the panelists, Patient Safety Learning's Chief Digital Office Clive Flashman, agreed with the other panel members that the NHS had become more collaborative and familiar with technology since Covid: “We’ve seen a definite increase in telehealth and telemeds. Covid has forced cultural blockers that were there before to be removed out of necessity. There has been a growth in robotic pharmacy automation to free up staff time from high volume administration tasks to do more complex work that adds value for patients.” But with the second-wave of COVID-19 still a very real threat he advised: “We don’t want to wait until the next wave to learn a lesson – we need to learn lessons now. Quality Improvement Leads should be focussed on what went right and what went wrong over that period between March and May. They need to be looking at what we can learn from that now and what we can do differently next time. If we don’t do that, we won’t succeed in the second wave where we might fail.” Ed Platt, Automation Director, Omnicell UK & Ireland, added: “Challenges within the NHS throughout Covid has forced them to embrace technology and drive innovation." "It’s important that when things go back to normal, we don’t go back to the same status quo. We need to invest in the right infrastructure in hospitals so unnecessary demands and stress are not put on pharmacy, supply managers and nurses so they are free to focus on patient care not administration tasks." Read full story Source: NHE, 17 September 2020 You can watch the webinar on demand here
  8. Content Article
    Surgical instruments are essential for the delivery of modern healthcare. Their use is so widespread that they are easily taken for granted. The supplier base for instruments is diverse, including small, family owned businesses, and large multinational corporations. What they have in common are complex manufacturing processes, global supply chains, broad product ranges to suit varying clinical needs and product development with the capacity to innovate as required.
  9. News Article
    A 33-year-old woman says she's been suffering awful coronavirus symptoms for six months and says it's "ruined her life". Stephanie, from London, says her symptoms began in mid-March when she started experiencing loss of taste and smell, body aches, headaches, a fever, shivering, hot and cold sweats, and sickness. But six months later she still has had no sense of taste and smell, she suffers brain fog and chronic fatigue and says just walking across her flat leaves her chest feeling tight. The photographer, who lives alone, says she sleeps for 10-12 hours but is still always tired. "I'm only 33," she said. Stephanie wants to raise awareness of 'long Covid' and says more research needs to be done on how to treat the long-term effects of the disease. She said she's scared she'll 'never be the same again'. Stephanie says she has a hospital appointment on Friday to have tests on her lungs and heart as doctors are concerned she has lung damage. She added: "I think some people don't believe in long Covid, so I want to raise awareness of what people are going through. We need more research of how to treat people with long Covid because there isn't much available, it's so awful." Read full story Source: Mirror, 1 October 2020
  10. Content Article
    European drug regulations aim for a patient-centered approach, including involving patients in the pharmacovigilance (PV) systems. However many patient organisations have little experience on how they can participate in PV activities. The aim of this study published in Drug Safety, was to understand patient organisations’ perceptions of PV, the barriers they face when implementing PV activities, and their interaction with other stakeholders and suggest methods for the stimulation of patient organisations as promoters of PV.
  11. News Article
    From the moment coronavirus reached UK shores, public health advice stressed the importance of washing hands and deep-cleaning surfaces to reduce the risk of becoming infected. The advice was informed by mountains of research into the transmission of other respiratory viruses: it was the best scientists could do with such a new pathogen. But as the pandemic spread and data rolled in, some scientists began to question whether the focus on hand hygiene was as crucial as it seemed. The issue has resurfaced after Monica Gandhi, a professor of medicine at the University of California, San Francisco, told the US science magazine Nautilus that the easiest way to catch the virus was through droplets and aerosols sprayed from an infected person’s mouth or nose. “It’s not through surfaces,” she said. “We now know the root of the spread is not from touching surfaces and touching your eye. It’s from being close to someone spewing virus from their nose and mouth, without in most cases knowing they are doing so.” Gandhi’s is not a lone voice. Her comments follow a prominent paper in the Lancet from Emanuel Goldman, a professor of microbiology at Rutgers University in New Jersey. He was sceptical about the relevance of scientific studies that showed the virus could survive on surfaces for days at a time. “In my opinion,” he wrote, “the chance of transmission through inanimate surfaces is very small, and only in instances where an infected person coughs or sneezes on the surface, and someone else touches that surface soon after the cough or sneeze.” He defined soon as within one to two hours. Dr Julian Tang, an honorary associate professor of respiratory sciences at the University of Leicester, thinks hand washing should stay but agrees the risk from contaminated surfaces has been overplayed. He points to documents from the UK government’s Scientific Advisory Group for Emergencies (Sage) that estimate hand washing can reduce acute respiratory infections by only 16%. Meanwhile, he adds, the World Health Organization has warned about surfaces being a likely route of transmission while conceding there are no reports demonstrating infection this way. Tang believes that a preoccupation with contaminated surfaces distracted countries from taking airborne transmission seriously and played down the necessity of wearing masks. “What we’ve always said is that the virus transmits by all routes. There might be some transmission by hand and fomites and we’re not opposed to hand washing, but the emphasis is wrong,” he told the Guardian. Read full story Source: 5 October 2020
  12. Content Article
    "The night shift in A&E started off as normal: routine heart attacks, head injuries, road traffic accidents, an array of minor injuries. It was what happened next that has stayed with me for 25 years, long after I left my job as a doctor in the NHS." In this blog for the Guardian, a doctor reflects on the impact a traumatic night in A&E has had on them and their concerns for the mental health and wellbeing of all frontline staff during this global pandemic. Their hope is that immediate funding for a national framework of in-house support and counselling will stem the tsunami of mental ill health among frontline workers that is coming, and shed light on the ultimate medical taboo that is the mental health of our healthcare staff.
  13. Content Article
    As the pandemic approached England in early 2020, government policy decisions ensured most people stayed at home and NHS hospitals were largely protected. Yet some lives were not saved that should have been and England subsequently experienced the highest levels of excess mortality in Europe. Now as we head towards a winter living with COVID-19, a new hospital discharge policy suggests the English NHS has not learned from early mistakes and may be putting the lives of vulnerable people at risk.
  14. News Article
    The Care Quality Commission (CQC) is to target poorly performing NHS maternity units after a series of maternity scandals. It is drawing up plans to spot high-risk maternity units and will use data on their patient outcomes and culture to draw up a list of facilities for targeted inspection. The watchdog has voiced concerns over the wider safety of maternity units in the NHS after a number of high-profile maternity scandals in the past year. Almost two-fifths of maternity units, 38%, are rated as “requires improvement” by the CQC for their safety. The Independent has joined with charity Baby Lifeline to call on the government to reinstate a national maternity safety training fund for doctors and midwives. The fund was found to be successful but axed after just one year. On Tuesday, the CQC’s chief inspector of hospitals, Professor Ted Baker, told MPs on the Commons Health and Social Care Committee that he was concerned about the safety of mothers and babies in some maternity units which had persistent problems. “Those problems are of dysfunction, poor leadership, of poor culture, of parts of the services not working well together,” he said. “This is not just a few units; this is a significant cultural issue across maternity services.” Now the CQC has confirmed it is planning to draw up a list of poor-performing units or hospitals where it suspects there could be safety issues. The new inspection programme will specifically look at issues around outcomes and teamworking culture although the full methodology has yet to be decided. Read full story Source: The Independent, 4 October 2020
  15. Content Article
    'Long Covid' is a term is used to describe individuals who continue to suffer from COVID-19 symptoms outside of the two-week period in which they are believed to be infected. The World Health Organization (WHO) endorsed this two-week period as enough time for the virus and its symptoms to be able to come and go, yet studies are revealing cases in which symptoms are persisting well outside of this window. Survivors may have a chronic debilitating illness for many months.
  16. Content Article
    RIDDOR puts duties on employers, the self-employed and people in control of work premises (the Responsible Person) to report certain serious workplace accidents, occupational diseases and specified dangerous occurrences (near misses). There is no requirement under RIDDOR (The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013) to report incidents of disease or deaths of members of the public, patients, care home residents or service users from COVID-19. The reporting requirements relating to cases of, or deaths from, COVID-19 under RIDDOR apply only to occupational exposure, that is, as a result of a person’s work.
  17. Content Article
    Medicine is a mirror for the racial injustice in our society; it is a field riddled with racial disparities in everything from research funding to patient care to life expectancy. There may be no population of patients whose healthcare and outcomes are more affected by racism than those with sickle cell disease (SCD). Patients with SCD are too often marginalised and dismissed while seeking medical care when their bodies hurt and they cannot breathe. As medical leaders around the United States issue statements denouncing racial injustice and calling for us to “dismantle racism at every level,” we must ensure that these pledges translate into durable improvements for patients with SCD. Alexandra Power-Hays and Patrick T. McGann propose a number of changes to reduce the impact of racism on patients with SCD in the US.
  18. Content Article
    Appalling racial inequities in health exist in nearly every realm that researchers have examined. These inequities are a dramatic manifestation of the structural violence that plagues our society. Deborah Cohan, an obstetrician, gives her perspective on this in her article in the New England Journal of Medicine. "How am I confronting the underlying forces that facilitate increased suffering and death among certain groups because of their skin color? Although it’s necessary, it is not enough for me to provide respectful health care to pregnant women of color. If I truly want to be part of the solution, I need to explore those parts of me that are most unwholesome, embarrassing, unflattering, and generally not discussed in the context of one’s career." Her goal is to dismantle the insidious thoughts that reinforce a hierarchy based on race, education, and other markers of privilege that separate her from others. "These thoughts, fed by implicit bias, are more common than I find easy to admit. Although I know not to believe everything I think, I also know that thoughts guide attention, and attention guides actions. Until I bring to light and hold myself accountable for my own racist tendencies, I am contributing to racism in health care."
  19. News Article
    A Dublin teenager has told of his harrowing battle with COVID-19 and is urging other young people to take the disease seriously. Jack Edge, 17, from Rathfarnham, had no underlying health conditions when he contracted the virus in April. Five months on and three hospital admissions later, the Leaving Cert student is still suffering from the "destruction" the virus wreaked on his body. Jack first displayed symptoms of COVID-19 on 15 April and five days later was admitted to Tallaght University Hospital. Within hours of being hospitalised, he was fighting for his life. Jack had to be put on a ventilator to help him breathe for 12 days. As his condition stabilised, he was transferred to a high dependency unit. Jack said: "I couldn't sleep for three days. Every time I closed my eyes, there was just dizziness and loads of colours. "I literally stayed in the bed for 72 hours, just staring at the wall. I had a lot of dark times in the hospital, since I do struggle with anxiety too." "But the care I received was absolutely amazing. They came in and talked to me if I needed to talk, as I would often get lonely, as it was mainly just me in an isolation room." However, surviving COVID-19 was just the first step for Jack. On 28 May, he was readmitted to hospital in excruciating pain. Doctors told him he may have suffered nerve damage associated with the virus. "I’m currently taking 18-20 tablets a day. Tablets for the nerve damage, for pain and for my anxiety. " "I basically have to learn to walk again. I do two to two-and-a-half hours of physio every day, depending on how much energy I have. I wake up some days and I get really upset. I still don’t know why this happened to me or how I got it." Jack hopes that by sharing his story he can raise awareness of the dangers and debilitating long-term effects of COVID-19 for young people. Read full story Source: RTE News, 2 October 2020
  20. News Article
    Next Thursday we’ll see more waiting list data released. What is contained in it is probably why Sir David Sloman’s office has taken nearly a month to not answer this question: Your letter to system leaders said you would “eliminate” 52-week waits, by when? The regional director’s office could not answer, nor could it reveal which hospitals were going to be the high-volume centre to burn through the lists in the six major specialities. There are a couple of likely reasons for their not being able to say when the long waiters would be eliminated. NHSI/E’s phase three letter set “mad” targets that don’t feel very real to many on the ground. I/E central will know this and have their own reasons for setting stretching-to-the-point-of-snapping targets, but trusts don’t really want to be held to submitting impossible commitments then being chastised for missing them (management teams have been moved on for this kind of thing in less fraught times). The second reason is that the picture is likely to be scary and also to have an impact on the ongoing three-way negotiation between the NHS, the independent sector - which will be hosting a lot of this work - and the workforce that will actually do it in both places. There is even less transparency than usual from the regional director’s office and I/E generally when asked anything at all about how effectively private sector facilities are being used, or how much it is costing. Much more surprising is the fact that Sir David’s office cannot yet name where each of the ICS’s six high-volume centres will be. Read full story (paywalled) Source: HSJ, 1 October 2020
  21. Content Article
    Ultrasound scans are important for checking the health of you and your baby. There are different types of scanning service and it's important to understand what each type offers. The Care Quality Commission provides some guidelines.
  22. Content Article
    Suffering from an eating disorders can impact on all parts of a person’s life and the NHS is committed to providing evidence based treatment and support to those who need it. The First Episode Rapid Early Intervention for Eating Disorders (FREED) is an innovative service model that has offered support to over 1,200 16 to 25-year-olds who have had an eating disorder for three years or less.
  23. Content Article
    The appointment of a Freedom to Speak Up (FTSU) Guardian is a requirement of the NHS Standard Contract in England. The National Guardian’s Office (NGO) provides leadership, support and guidance to FTSU Guardians. This report from the NGO covers the period 1 April 2019 to 31 March 2020.
  24. News Article
    October is Speak Up Month – a chance to raise awareness of Freedom to Speak Up and the work which is going on in organisations to make speaking up business as usual. 2020 has been an extraordinary year, and all NHS workers, whatever their role, have been under increased pressure from the COVID-19 crisis. Throughout October the National Guardian Freedom to Speak Up will be sharing their Alphabet of Speak Up – from Anonymity to Zero Tolerance. 26 days to explore the issues, the people, the values, the challenges – everything which goes into what Freedom to Speak Up means in health. #SpeakUpABC National Guardian Freedom to Speak Up
  25. Content Article
    When things go wrong, we seem to display a reliable tendency to do one thing: blame those at the ‘sharp end’. No matter how complex the system, how uncertain the situation, or how inadequate the conditions, our attention post-accident seems to turn to those proximal to the consequence, whom we judge to have failed to control the hazard in question. The notion of ‘just culture’ has developed over the past decade or so in response to this and is highly valued by front line staff. Just culture is, however, borne of the Safety-I mindset. Since the advent of ‘just culture’, the Safety-II perspective has emerged. Safety-II defines safety not as avoiding that things go wrong but as ensuring that things go right. Safety-II views the human not as a hazard, but as a resource necessary for system flexibility and resilience. In light of this, it has been proposed that the idea of just culture should be abandoned. If we take a Safety-II view, ‘just culture’ might indeed seem unnecessary. Steve Shorrock explores this further in his latest blog.
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