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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Less than half of the UK population will get a Covid vaccine with the elderly being top priority - a top advisor has warned. Kate Bingham, who was appointed as the chair of the Vaccine Taskforce back in May has claimed that the public has been “misguided” when it comes to availability of a vaccine. In an interview with the Financial Times, she said the government “needs to vaccinate everyone at risk”. She said: “People keep talking about ‘time to vaccinate the whole population’, but that is misguided." “There’s going to be no vaccination of people under 18. It’s an adult-only vaccine, for people over 50, focusing on health workers and carehome workers and the vulnerable.” Read full story Source: Financial Times, 4 October 2020
  2. Content Article
    Trusts and frontline staff are working flat out to restore those services which were necessarily interrupted to cope with the first peak of the pandemic. NHS Providers' Restoring services: NHS activity tracker highlights detailed examples of the innovations trusts and their staff developing to improve capacity, and respond to unmet demand despite the constraints created by COVID-19, and the need to prepare for additional winter pressures. 
  3. Content Article
    Slow-lane logistics shouldn’t stymie fast-track science, says head of UK government’s Vaccine Taskforce, Kate Bingham, in this Nature article. Kate was appointed chair of the UK Vaccine Taskforce in May. The main job of this Taskforce is to identify, manufacture and develop the most promising pandemic vaccines and deliver them rapidly to the populations that need them. COVID-19 is an opportunity to create a permanent system for supplying vaccines for future pandemics, quickly and safely; this process must become as routine and reliable as crafting the yearly influenza vaccine, says Kate. Time and again, outstanding science has been slowed down by the ‘boring stuff’ — practicalities. That includes delays in manufacturing scale-up and legal approvals slowing pivotal US trials of one of my UK company’s potentially life-saving drugs, or progress hampered by logistics, regulatory disagreements and inadequate data disclosure. Often, the problem is not the science or the clinical trials, but the infrastructure. We must take pains now to make sure this does not stall future pandemic vaccines.
  4. Content Article
    Neurological symptoms are seen in patients with COVID-19 and can persist or re-emerge after clearance of SARS-CoV-2. Recent findings suggest that antibodies to SARS-CoV-2 can cross-react with mammalian proteins. Focusing on neurological symptoms, Kreye et al. discuss whether these cross-reactive antibodies could contribute to COVID-19 disease pathology and to the persistence of symptoms in patients who have cleared the initial viral infection.
  5. Event
    HSJ editor Alastair McLellan will be chairing a webinar on building a healthy and health-creating society – partnerships between the health creators, the NHS and government. Panellists will include Lord Victor Adebowale, chair of the NHS Confederation, Dame Donne Hall, chair of the New local Government Network, Merron Simpson, CEO of New NHS Alliance, Dr Gillian Orrow of Horley, and Lord Nigel Crisp. Register
  6. News Article
    A pair of Conservative former ministers have announced they are to lead a rapid, cross-party investigation into the UK’s handling of the coronavirus crisis, amid worries a government inquiry will take too long for lessons to be learned in time. In a rare set of joint hearings, the Commons health committee, led by ex-health secretary Jeremy Hunt, and the science committee, chaired by Greg Clark, who was business secretary, are to hear from witnesses in the hope of producing a report by the spring. Announcing the plan, Hunt and Clark said the inquiry would aim to produce interim recommendations along the way. It will hold weekly joint sessions, with early witnesses set to include Chris Whitty, the chief medical officer for England, and Patrick Vallance, the government’s top scientific adviser. Hunt said he would expect the inquiry to cover the need for regular, large-scale coronavirus testing, an issue he has repeatedly raised in parliament, and whether this could help people visit loved ones in care homes. The hearings begin next Tuesday with a session on social care. Other promised areas of examination include the efficacy of lockdown measures; how well modelling and statistics have been used; the efficacy of government messaging; wider preparedness for a pandemic; and the impact on BAME communities. Read full story Source: The Guardian, 8 October 2020
  7. Content Article
    The NHS should learn lessons from health creators that use a holistic approach to health and wellbeing, creating conducive environment for people to flourish, says Nigel Crisp in this blog for HSJ. Creating health is about creating the conditions for people to be healthy and helping them to be so. It’s what parents do and good teachers and schools – creating healthy, resilient, confident individuals. One of they ways health creators do things differently from the usual NHS and public sector approach is their emphasis on relationships – people get things done primarily through building relationships rather than by just following systems.Their approach is vision and goal-led (rather than plan-led) so people learn by doing, being experimental, adaptable and entrepreneurial. And it is about doing things that have meaning and purpose and not just about processes, checklists and plans. Read Nigel's book: Health is made at home, hospitals are for repairs
  8. Content Article
    Patient Safety Learning’s response to the announcement by the NHS on the 7 October 2020 of a new five-part package of measures to boost support for Long Covid patients.
  9. Content Article
    The Clinical Command Centre is designed to optimise many aspects of day-to-day patient care and help create better patient experiences, outcomes, and lower costs. It makes sense of vast amounts of data for hospitals and healthcare systems worldwide.  Today, Command Centres are also helping these systems meet the challenge of COVID-19. Currently, Bradford Teaching Hospitals NHS Foundation Trust (BTHFT) is the only Trust in Europe equipped with this technology which is likely to be crucial in dealing with any second wave of COVID-19 cases.  In this video, Mel Pickup, CEO of BTHFT, shed some light on how they've been using advanced data visualisation and the vision for using it in the future. By making sense of vast amounts of operational data, the technology is enabling leadership teams to make critical, real-time decisions about patient care.
  10. Event
    This virtual conference will focus on measuring, understanding and acting on patient experience insight, and demonstrating responsiveness to ensure Patient Feedback is translated into quality improvement and assurance. Through national updates and case study presentations the conference will support you to measure, monitor and improve patient experience in your service, and ensure that insight leads to quality improvement. Book your place or email kerry@hc-uk.org.uk hub members can receive a 20% discount by quoting HCUK20psl when booking Follow the conference on Twitter ##PatientExp
  11. Event
    Aimed at clinicians and managers, this national conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process and safety. You will have the opportunity to network with colleagues who are working to embed a human factors approach, self-assess and reflect on your own practice and gain CPD accreditation points contributing to professional development and revalidation evidence. Book your place or email kerry@hc-uk.org.uk hub members can receive a 20% discount. Email info@pslhub.org to receive the discount code. Follow the conference on Twitter #HumanFactors
  12. Content Article
    This Take, Treat and Test webinar took place on 10 September 2020, presented by Dr Ron Daniels, Founder, and Executive Director – Clinical – Sepsis Trust UK and Consultant in Critical Care and Anaesthesia, University Hospitals Birmingham NHS Foundation Trust.
  13. Community Post
    Thank you 'Gerdayoga' for your post and I'm sorry to hear you're struggling with this. Here's the link to the Iyengar Yoga covid recovery programme you mention: https://iyengaryoga.org.uk/covid-19-a-suggested-recovery-programme/ so others can take a look. If you would like to continue the discussion please do post again or you can email us directly at content@pslhub.org. We are collating all feedback and can maintain your anonymity if you prefer.
  14. News Article
    NHS England will spend £10m on new clinics for ‘long covid’ sufferers, it was announced yesterday. Sir Simon Stevens, NHSE chief executive, told the NHS Providers annual conference the clinics would offer support to the “probably hundreds of thousands” of people suffering persisting symptoms such as fatigue, breathlessness and ‘brain fog’ months after being infected with COVID-19. It comes amid growing calls for wider services to support people with ‘long covid,’ as hospital follow-up clinics are generally only open to those who were previously admitted with the virus. HSJ was last month only able to identify one genuine “long covid clinic”, despite claims by health secretary Matt Hancock they had “announced them in July”. It appears that comment was a mistake. Speaking about long covid, he said: “The NHS has got to be just as responsive and agile in respect of… new needs, including long covid, as we were in repurposing critical care, and ventilators, and acute capacity in the first phase in March, April and May." “Today we are going to be allocating £10m to establish a network of designated long covid clinics across the country, which, in line with new NICE guidelines on effective treatment pathways, will offer support for the tens of thousands, probably hundreds of thousands, of patients who have got long covid.” Sir Simon also told the conference today that NHSE was “enthusiastic” about introducing regular asymptomatic covid testing for NHS staff “if and when” it is recommended by the government chief medical officer, and when Test and Trace has enough capacity. There are growing calls for regular testing of asymptomatic NHS staff, especially in hotspot areas, including from former health secretary Jeremy Hunt. Sir Simon said it was “something the chief medical officer and the test and trace programme are continuing to review”. He said: “We would be enthusiastic about doing that if and when that is the clinical recommendation and if and when the Test and Trace programme has got the testing capacity to do that. The plan was always that it would largely have to be sourced out of the total testing capacity available to the nation, not just the NHS labs.” Read full story Source: HSJ, 7 October 2020 Read Patient Safety Learning's response to this news Please share your thoughts with us on the support that is needed on our patient safety platform, the hub.
  15. News Article
    The care model run by independent sector mental health and learning disability hospitals is ‘inherently risky’, a Care Quality Commission (CQC) chief inspector has warned. Speaking at the NHS Providers conference, Ted Baker, chief inspector of hospitals for the Care Quality Commission, unveiled the regulator’s plans to change how it inspects health and care services. When asked by HSJ how its new “streamlined” approach would be applied to inpatient units run by the independent sector for people with mental health and learning disability, Professor Baker said: ”One of the things we’ve been doing during the pandemic, and will continue in our transitional approach, is target risk. And one of the risks we have been targeting is exactly this, patients with learning disability and/or autism in some of these small units that have got closed cultures." “I think we do recognise that model of care is an inherently risky model of care and so we have been inspecting many of those under this risk driven model and taking action against many of them. But there is ongoing concern about that model of care and in a few weeks’ time we will be publishing a report on our assessment of that model of care and the importance of it being changed for the benefit of the people being looked after. The model of care needs to be improved but we need to make sure we are tackling the risk.” The chief’s comments come ahead of the regulator’s state of care report, which is due to be published next week. In its report published last year the CQC highlighted a concern regarding the quality and safety of independent learning disability and autism units. In particular it warned these were at a higher risk of developing closed cultures. Read full story (paywalled) Source: HSJ, 7 October 2020)
  16. News Article
    A baby died during birth because of systemic errors in one of Britain's largest NHS hospitals, months after staff had warned hospital chiefs that the maternity unit was “unsafe”, an inquest has found. A coroner ruled that neglect by staff at Nottingham University Hospitals Trust contributed to the death of baby Wynter Andrews last year. She was delivered by caesarean section on 15 September after significant delays. Her umbilical cord was wrapped around her neck and leg, resulting in her being starved of oxygen. In a verdict on Wednesday, assistant coroner Laurinda Bower said Wynter would have survived if action had been taken sooner, criticising the units “unsafe culture” and warning that her death was not an isolated incident. Wynter’s mother, Sarah Andrews, called on the health secretary, Matt Hancock, to investigate the trust’s maternity unit. She said: “We know Wynter isn’t an isolated incident; there have been other baby deaths arising because of the trust’s systemic failings. She was a victim of the trust’s unsafe culture and practices.” Read full story Source: The Independent, 7 October 2020
  17. Content Article
    Advances in 3D printing, also called additive manufacturing, are capturing attention in the healthcare field because of their potential to improve treatment for certain medical conditions. A radiologist, for instance, might create an exact replica of a patient’s spine to help plan a surgery; a dentist could scan a broken tooth to make a crown that fits precisely into the patient’s mouth. In both instances, the doctors can use 3D printing to make products that specifically match a patient’s anatomy. The technology is not limited to planning surgeries or producing customised dental restorations such as crowns; 3D printing has enabled the production of customized prosthetic limbs, cranial implants, or orthopedic implants such as hips and knees. At the same time, its potential to change the manufacturing of medical products—particularly high-risk devices such as implants—could affect patient safety, creating new challenges for Food and Drug Administration (FDA) oversight. When 3D printing is used to manufacture a medical product at the point of care, oversight responsibility can become less clear. It is not yet apparent how the agency should adapt its regulatory requirements to ensure that these 3D-printed products are safe and effective for their intended use. The FDA does not directly regulate the practice of medicine, which is overseen primarily by state medical boards. Rather, the agency’s jurisdiction covers medical products. In some clinical scenarios where 3D printing might be used, such as the printing of an anatomical model that is used to plan surgery, or perhaps one day the printing of human tissue for transplantation, the distinction between product and practice is not always easy to discern. This issue brief explains how medical 3D printing is used in health care, how FDA regulates the products that are made, and what regulatory questions the agency faces.
  18. News Article
    Doctors are being told to "think carefully" before ordering any tests for their patients, amid shortages caused by a supply chain failure at a major diagnostics company. Swiss pharmaceutical firm Roche said problems with a move to a new warehouse had led to a "very significant" drop in its processing capacity. A spokesman said COVID-19 tests would be prioritised, but the backlog could affect tests including for cancer and heart disease. One NHS trust in the south west has already advised its GPs to stop all non-urgent blood tests. A memo seen by the BBC, sent to clinicians within a large hospital trust in London, said leaders were "preparing for a sustained disruption". "We urgently need all clinical teams to only send tests that are absolutely essential for immediate patient care, delaying testing where possible," it said. Thyroid and cortisol tests were unavailable, while certain cholesterol, liver function and inflammation tests were "severely restricted". Read full story Source: BBC News, 7 October 2020
  19. News Article
    Patients who saw a pain medicine specialist via telemedicine saved time and money and were highly satisfied with their experience, even before the COVID-19 pandemic, according to a study presented at the ANESTHESIOLOGY® 2020 annual meeting. Results of the study confirm many chronic pain patients are confident they will receive good care via telemedicine, while avoiding lengthy commutes and time spent in traffic. "This era of contactless interactions and social distancing has really accelerated the adoption of telemedicine, but even before the pandemic, patient satisfaction was consistently high," said Laleh Jalilian, M.D., lead author of the study and clinical assistant professor at the University of California, Los Angeles (UCLA). "Patients who are being evaluated for new conditions may be better off having office visits initially. But once patients establish a relationship with providers, follow-up visits can occur efficiently with telemedicine, while maintaining patient rapport and quality outcomes. We believe 50% of our visits could be conducted via telemedicine." "Now that telemedicine is more widespread, it may become a valued part of care delivery in chronic pain practices," said Dr. Jalilian. "Clearly many patients benefitted from remote consultations and follow-up appointments using telemedicine. We hope it will encourage policymakers and insurance providers to continue to support these platforms and inspire more innovation in this developing field of research and patient care." Read full story Source: EurekAlert, 5 October 2020
  20. Content Article
    Suzette Woodward reflects on the recent reports and research into maternal safety and why we need to shift to a Safety II approach.
  21. News Article
    People suffering 'Long Covid’ symptoms will be offered specialist help at clinics across England, the head of the NHS announced today. Respiratory consultants, physiotherapists, other specialists and GPs will all help assess, diagnose and treat thousands of sufferers who have reported symptoms ranging from breathlessness, chronic fatigue, 'brain fog', anxiety and stress. Speaking at the NHS Providers conference today (Wednesday), NHS chief executive Sir Simon Stevens will announce that £10 million is be invested this year in additional local funding to help kick start and designate Long Covid clinics in every area across England, to complement existing primary, community and rehabilitation care. Sir Simon said new network will be a core element of a five-part package of measures to boost NHS support for Long Covid patients: New guidance commissioned by NHS England from NICE by the end of October on the medical ‘case definition’ of Long Covid. This will include patients who have had covid who may not have had a hospital admission or a previous positive test. It will be followed by evidence-based NICE clinical guidelines in November on the support that Long Covid patients should receive, enabling NHS doctors, therapists and staff to provide a clear and personalised treatment plan. This will include education materials for GPs and other health professionals to help them refer and signpost patients to the right support. The ‘Your Covid Recovery’ – an online rehab service to provide personalised support to patients. Over 100,000 people have used the online hub since it launched in July, which gives people general information and advice on living with Long Covid. Phase 2 of the digital platform will see people able to access a tailored rehabilitation plan. This service will be available to anyone suffering symptoms that are likely due to COVID-19, regardless of location or whether they have spent time in hospital. Designated Long Covid clinics, as announced today. This will involve each part of the country designating expert one-stop services in line with an agreed national specification. Post-covid services will provide joined up care for physical and mental health, with patients having access to a physical assessment, a cognitive assessment and a psychological assessment. Patients could also then be referred from designated clinics into specialist lung disease services, sleep clinics, cardiac services, rehabilitation services, or signposted into IAPT and other mental health services. NIHR- funded research on Long Covid which is working with 10,000 patients to better understand the condition and refine appropriate treatment. The NHS’s support will be overseen by a new NHS England Long Covid taskforce which will include Long Covid patients, medical specialists and researchers. Read full story Source: NHS England, 7 October 2020 Read Patient Safety Learning's response to this news Please share your thoughts with us on the support that is needed on our patient safety platform, the hub.
  22. Content Article
    A short article from NHS Education for Scotland about Significant event analysis (SEA). Enhanced SEA is a well-established safety improvement tool in general practice. However, there is good evidence to suggest that many SEAs are poorly conducted by practice teams, leading to missed opportunities to make health care safer.
  23. News Article
    Almost half of NHS Trusts in England have reported risks classified as “significant” or “extreme”, with issues facing funding, buildings and failing equipment, according to an analysis by Labour. Highlighting warnings of staff shortages and patient safety, the party demanded urgent action from the government to prepare the health service for the winter months as cases of COVID-19 accelerate across the country. Labour said its study of 114 NHS Trusts’ risks registers showed that over three quarters of trusts logged a workforce risk. The analysis also revealed that 66% reported a financial risk, 82% highlighted risks directly related to COVID-19 and 84% recorded a risk to patient safety. Almost half of Trusts (54), the party said, had outlined risks described as “significant” or “extreme”. One hospital trust reported it was “not financially stable” beyond the current financial year while another recorded a potential risk to patient safety due to “structural deficiencies” in roof structure. NHS hospitals are expected to consider risks to their operations and processes and when risks are identified, it is likely they will have been considered at board level and mitigations put in place. Describing the registers – compiled between March and August - as “worrying” in a normal winter, Jonathan Ashworth, the shadow health secretary, said: “In the coming winter, with the incompetent handling of the test and trace system leaving the NHS wide open and poorly supported, they take on a whole new meaning." "We urgently need a commitment from ministers to fix the problems with test and trace and a timetable by which these issues will finally be sorted. On top of this it is vital that ministers confirm that the NHS will get the additional support it needs to address these risks." Read full story Source: The Independent, 6 October 2020
  24. Event
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    This high profile conference will be attended by GPs, Social Prescribing Link Workers, Social Prescribing programmes, Community, Health and Social Care industry leaders, Primary Care Networks, Clinical Directors, Practice Managers and Line Managers from across sectors in the United Kingdom. Celebrate, network, discover the latest updates and learn best practices to power up community wellbeing through social prescribing. Further information and registration
  25. Content Article
    The aim of this study from Jardine et al. was to determine the rate of complicated birth at term in women classified at low risk according to the National Institute for Health and Care Excellence guideline for intrapartum care (no pre-existing medical conditions, important obstetric history, or complications during pregnancy) and to assess if the risk classification can be improved by considering parity and the number of risk factors. The authors found nulliparous women without risk factors have substantially higher rates of complicated birth than multiparous women without a previous caesarean section even if the latter have multiple risk factors. Grouping women first according to parity and previous mode of birth, and then within these groups according to presence of specific risk factors would provide greater and more informed choice to women, better targeting of interventions, and fewer transfers during labour than according to the presence of risk factors alone.
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