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Patient Safety Learning

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  1. Event
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    This is a global online event from the Royal College of Surgeons of Edinburgh, relevant to all who work in healthcare, with a focus on the role of the surgical team in delivering care. Everyone is invited to register for this free online event. The participants will be encouraged to use a smartphone or another second screen to actively participate and answer questions. This event will be delivered on Zoom – questions can be submitted, and the use of the chat room is encouraged. Registered participants will get a copy of the webinar recording, slides, questions and answers, chat room, Menti results and a Spotify playlist. The conference panel is formed of a diverse group of experts with a range of skills in healthcare, surgery, education, business, leadership, coaching, training, human factors, and situational awareness. They have experience working with high performance teams, global industries, firefighters, aircrews, and fighter pilots in theatres of operation, cockpits, and on oil rigs. All have worked in high performance teams and understand the critical importance of listening and communication. The conference is headlined by the global leader, Bob Chapman, CEO of Barry-Wehmiller and co-author of the bestselling book; ‘Everybody Matters – the extraordinary power of caring for your people like family’. Further information and registration
  2. Event
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    Unprecedented levels of change have taken place in the design, service and delivery of health care services in the space of months. COVID-19 has upended our understanding of good, quality care, with many barriers removed instantly and new ideas deemed too radical a couple of months ago, becoming our ‘new normal’. This new reality, with the essential limitations on physical contact has resulted in digital solutions taking centre stage in tackling the pandemic, providing care and ensuring continuity of care for patients across the country. In this event, we will examine the insights our current reality teaches us about how we have delivered digital health in the past. Were some of the barriers safeguards of quality standards and patient safety benchmarks? Are there reasons to be worried about the speed of transformation? And how can we ensure that we keep the good changes and mitigate the negative? Join The King's Fund free online event to discuss: what an inclusive, person-centred digital revolution would look like for the NHS and social care the standards from before the pandemic and what the gains from this rapid transformation should consolidate what this transformation will mean for people and staff on the ground. Further information and registration
  3. News Article
    Ministers have been accused of trying to cover up the findings from investigations into hundreds of health and social care worker deaths linked to coronavirus after it emerged the results will not be made public. The Independent revealed on Tuesday that medical examiners across England and Wales have been asked by ministers to investigate more than 620 deaths of frontline staff that occurred during the pandemic. The senior doctors will review the circumstances and medical cause of death in each case and attempt to determine whether the worker may have caught the virus during the course of their duties. But now the Department of Health and Social Care (DHSC) said the results will be kept secret with the aim of helping local hospitals to learn and improve protection for staff. Separately, trade unions and NHS Providers, which represents hospital trusts, have urged the government to ensure full investigations into every death and to be transparent about findings to reassure health and social care staff ahead of any second wave. Sir Ed Davey, acting leader of the Liberal Democrats, said: “We currently have one of the highest number of deaths of health and care workers in Europe. The government has utterly failed to protect staff in both hospitals and care homes. The fact that now they are trying to cover up how and why each tragic death occurs is a disgrace." Read full story Source: The Independent, 15 August 2020
  4. News Article
    Almost a million people waited at least half an hour for an ambulance after having a medical emergency such as a heart attack or stroke last year, NHS figures show. Ambulance crews responding to 999 calls in England took more than 30 minutes to reach patients needing urgent care a total of 905,086 times during 2019–20. Of those, 253,277 had to wait at least an hour, and 35,960 – the equivalent of almost 100 patients a day – waited for more than two hours. In addition to heart attacks and strokes, the figures cover patients who had sustained a serious injury or trauma or major burns, or had developed the potentially lethal blood-borne infection sepsis. Under NHS guidelines, ambulances are meant to arrive at incidents involving a medical emergency – known as category 2 calls – within 18 minutes. The Liberal Democrat MP Layla Moran, who obtained the figures using freedom of information laws, said: “It’s deeply shocking that such huge numbers of seriously ill patients have had to wait so long for an ambulance crew to arrive after a 999 call. It shows the incredible pressure our ambulance services were under even before this pandemic struck. “Patients suffering emergencies like a heart attack, stroke or serious injury need urgent medical attention, not to be left waiting for up to two hours for an ambulance to arrive. These worryingly long delays in an ambulance reaching a seriously ill or injured patient could have a major long-term impact on their health.” Read full story Source: The Guardian, 16 August 2020
  5. News Article
    Two hundred thousand defective gowns supplied to NHS hospitals have been recalled by the government because of fears they could leave staff at increased risk of coronavirus infection. Hospitals have been told to check their stocks of personal protective equipment (PPE) to identify the Flosteril non-sterile gowns and quarantine them immediately. The Department of Health and Social Care (DHSC) said tests carried out on the gowns, which were delivered in June, had shown that they did not meet the fluid-resistance standards originally claimed by the manufacturer. There may also be “inconsistencies” in the material used to make the gowns. An estimated 200,000 gowns are thought to be in circulation within the NHS after 600,000 were supplied by the company Vannin Healthcare Global, which is registered in the Isle of Man. Hospitals were told on Tuesday this week not to dispose of the gowns but to keep them for two weeks until they can be collected after 31 August. It is another embarrassing blow for the government over the supply of PPE to hospitals – an issue that prompted major criticism during the height of the COVID-19 crisis, when many hospitals ran out of equipment. Read full story Source: The Independent, 15 August 2020
  6. News Article
    Public Health England (PHE) is to be replaced by a new agency that will specifically deal with protecting the country from pandemics, according to a report. The Sunday Telegraph claims Health Secretary Matt Hancock will this week announce a new body modelled on Germany's Robert Koch Institute. Ministers have reportedly been unhappy with the way PHE has responded to the coronavirus crisis. A Department of Health and Social Care spokesperson said: "Public Health England have played an integral role in our national response to this unprecedented global pandemic." "We have always been clear that we must learn the right lessons from this crisis to ensure that we are in the strongest possible position, both as we continue to deal with Covid-19 and to respond to any future public health threat." The Telegraph reports that Mr Hancock will merge the NHS Test and Trace scheme with the pandemic response work of PHE. The paper said the new body could be called the National Institute for Health Protection and would become "effective" in September, but the change would not be fully completed until the spring. Read full story Source: BBC News, 16 August 2020
  7. Content Article
    The dangers of health care in Britain have been long understood. Systematic data collection of the hazards of health care can be traced back at least to the time of Florence Nightingale's publications in the 1860s. This short paper from Susan Burnett and Charles Vincent, outlines the evolution of patient safety and trace its development and progress over the last 10 years in Britain, where a nationalised health service and sustained commitment from Chief Medical Officer Sir Liam Donaldson and other senior figures have brought patient safety to considerable prominence.
  8. Content Article
    This overview considers how the NHS has performed over the current parliament in relation to patient safety. It looks at data relating to reported incidents and harm, episodes of care free of certain types of harm, and patient and staff perceptions of safety.
  9. Content Article
    A toolkit for healthcare staff has been published by the National Tracheostomy Safety Project (NTSP) in collaboration with the AHSN Network and the National Patient Safety Improvement Programmes in response to the COVID-19 pandemic, to support healthcare staff who are looking after patients with tracheostomies. The number of patients requiring relatively prolonged ventilatory support in intensive care units due to COVID-19 has led to increased numbers of patients requiring tracheostomies, which are used to help wean some patients from respiratory support. The toolkit provides information, practical resources and links to useful online training videos and websites. Primarily the toolkit is for hospital staff. However, much of the material is also applicable to primary and community care settings.
  10. Content Article
    An overview of the industry study by MxD and IAAE between February and June 2021 funded by FDA Office of Counterterrorism and Emerging Threats. The aim of the study was to gain an initial baseline to deepen FDA’s understanding of the factors that impact a manufacturer’s decision to invest in and adopt digital technologies by illuminating both perceived and demonstrated barriers from technical, business, and regulatory perspectives, and related cybersecurity considerations.
  11. Content Article
    Progress enables the creation of more automated and intelligent machines with increasing abilities that open up new roles between humans and machines. Only with a proper design for the resulting cooperative human–machine systems, these advances will make our lives easier, safer and enjoyable rather than harder and miserable. Starting from examples of natural cooperative systems, the paper from Flemisch et al. investigates four cornerstone concepts for the design of such systems: ability, authority, control and responsibility, as well as their relationship to each other and to concepts like levels of automation and autonomy.
  12. Content Article
    The number of publicly reported deaths from coronavirus disease 2019 (COVID-19) may underestimate the pandemic’s death toll. Such estimates rely on provisional data that are often incomplete and may omit undocumented deaths from COVID-19. Moreover, restrictions imposed by the pandemic (eg, stay-at-home orders) could claim lives indirectly through delayed care for acute emergencies, exacerbations of chronic diseases, and psychological distress (eg, drug overdoses). This study from Woolf et al. estimated excess deaths in the early weeks of the pandemic and the relative contribution of COVID-19 and other causes.
  13. Event
    The Patient Safety Movement Foundation is proud to partner with MedStar Health to offer free Continuing Education (CE) credit for this patient safety webinar. With Dr. Arthur Kanowitz, Dr. Sarah Kandil, Dr. Edwin Loftin, Dr. Anne Lyren, Dr. Kevin McQueen and Dr. Lauren Berkow. Free CE offered for physicians and nurses. This activity has been approved for AMA PRA Category 1 Credits™ and ANCC contact hours. Registration
  14. Event
    The Patient Safety Movement Foundation is proud to partner with MedStar Health to offer free Continuing Education (CE) credit for this patient safety webinar. With Patricia Merryweather-Arges, Dr. Ronald Wyatt, Dr. Daria Terrell, and Dr. Marcus Robinson. M Free CE offered for physicians, nurses, and pharmacists. This activity has been approved for AMA PRA Category 1 Credits™ and ANCC contact hours. Register
  15. Event
    This masterclass will provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide guidance on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Anyone with responsibility for implementing the duty of candour should attend, whether as a health or social care professional or at an organisational level, be it in the NHS, private healthcare or social care. Health and social care professionals; staff with responsibility for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending. Further information and registration
  16. Event
    This masterclass will provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide guidance on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Anyone with responsibility for implementing the duty of candour should attend, whether as a health or social care professional or at an organisational level, be it in the NHS, private healthcare or social care. Health and social care professionals; staff with responsibility for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending. Further information and registration
  17. News Article
    Unprecedentedly poor waiting time data for electives, diagnostics and cancer suggests the chances of NHS England’s ambitions for ‘near normal’ service levels this autumn being met are very unlikely, experts have warned. The statistics prompted one health think tank to urge NHS leaders to be “honest that with vital infection control measures affecting productivity, and a huge backlog, there are no shortcuts back to the way things were”. NHS England data published today revealed there were 50,536 patients who had been waiting over a year for elective treatment as of June – up from 1,613 in February before the covid outbreak, a number already viewed as very concerning. The number represents the highest level since 2009 and 16 times higher than they were in March. Nuffield Trust deputy director of research Sarah Scobie said: “These figures are a serious warning against any hope that the English NHS can get planned care back to normal before winter hits. The number of patients starting outpatient treatment is still a third lower than usual and getting back to 100 per cent by September will be a tall order.” “The increase in patients waiting more than a year has continued to accelerate at a shocking pace, with numbers now at their highest since 2009 and 16 times higher than they were in March. “Unfortunately, despite the real determination of staff to get back on track, some of these problems are set to grow… We need to be honest that with vital infection control measures affecting productivity, and a huge backlog, there are no shortcuts back to the way things were.” Read full story (paywalled) Source: HSJ, 13 August 2020
  18. News Article
    GP leaders have written to NHS England to demand that an NHS hospital trust urgently restores routine referrals as it has 'closed its doors' to some patients, ‘destabilising’ practices in the process. Oxfordshire LMC said local GPs are ‘concerned and angry’ about the ‘ongoing closure’ to routine referrals across multiple ‘high-demand’ specialties by Oxford University Hospital Foundation Trust, while warning GPs are also being asked to carry out tests that should be done in hospital. A ‘significant’ number of specialties are affected, including ENT, general gynaecology, dermatology, ophthalmology, endoscopy and urology, as well as plastics and maxillofacial, it added. The hospital trust said it had remained open for urgent and emergency care and was accepting clinically urgent and suspected cancer referrals, while reinstating services to support 'the vast majority' of routine referrals. But Oxfordshire LMC has this week written to NHS England and the council of governors at OUHFT to demand that there are ‘no further delays’ in restoring the services amid concerns of ‘patient harm’. It said: ‘The LMC believes the continuing closure of some specialty services to routine referrals is now so serious for patients that it has taken a decision to formally raise the concerns of Oxfordshire’s GPs with NHS England.’ Read full story Source: Pulse, 13 August 2020
  19. News Article
    A damning new report has exposed numerous lapses in nursing care on wards at Shrewsbury and Telford Hospital Trust amid a culture which left patients at risk of “unsafe and uncaring” treatment, the care watchdog has said. Inspectors from the Care Quality Commission (CQC) cited multiple examples of nurses at the scandal-hit trust lacking the knowledge to look after patients safely and failing to record key information needed to keep patients safe during an inspection of medical wards in June this year. The inspectors found poorly completed nursing records, equipment unavailable and nurses not following procedures. This meant some patients developed pressure sores, fell from their beds and were injured or suffered pain at the end of their life. Other patients were at risk of suffering similar harm. Inspectors ruled the trust, which was rated inadequate and put into special measures in 2018, was unsafe and criticised the hospital leadership for what it said was a “collective failure” that was perpetuating the problems at the hospital. Read full story Source: The Independent, 14 August 2020
  20. News Article
    The new version of the government’s contact tracing app will give users a ‘risk score’ based on how many people they interact with and where they live. The news comes as the Department of Health and Social Care launches a trial for the latest model of the contact tracing app, two months after the initial version was scrapped. According to the DHSC, the new app will tell users whether their risk of contracting coronavirus is unknown, low or high based on how many people they are in significant contact with. They will also be told what the coronavirus risk level is in their local authority area and will be alerted if it changes. Government guidance said the risk levels and alerts will be based on a local authority watchlist – which highlights areas that are of particular concern across the country, based on the number of coronavirus cases. People will also be able to check into venues – such as restaurants, pubs and leisure centres – using the app by scanning a QR code. If there is then an outbreak in a venue those who have checked in via the app will be alerted and told to isolate. The new NHS Test and Trace app trial was launched today for residents on the Isle of Wight and will expand to the London borough of Newham next week. Read full story (paywalled) Source: HSJ, 13 August 2020
  21. News Article
    A cosmetic surgeon who did not have adequate insurance for operations that went wrong has been struck off. Dr Arnaldo Paganelli worked privately for The Hospital Group in Birmingham. The Medical Practitioners' Tribunal Service ruled his actions constituted misconduct. Four women took their case to the body and the tribunal heard evidence about his time at Birmingham's Dolan Park Hospital where he made regular trips from Italy to work. Lead campaigner Dawn Knight, from Stanley, County Durham, said too much skin was removed from her eyes during an eyelift in 2012 and they became "constantly sore". She told BBC Radio 4's You and Yours programme she felt relieved Dr Paganelli "cannot injure anyone else on UK soil" and called for the government to tighten regulation around cosmetic procedures to protect the public. "The process has been long, emotional and exhausting. This situation must never be repeated. After all, when are you more vulnerable than when under aesthetic at the hands of a surgeon who has no insurance?" Read full story Source: BBC News, 12 August 2020
  22. Content Article
    Half of COVID-19 patients who received a heart scan in hospital showed abnormalities in heart function, according to new research funded by the British Heart Foundation. In this study, Dweck et al. describe the cardiac abnormalities in patients with COVID-19 and identify the characteristics of patients who would benefit most from echocardiography.
  23. News Article
    NHS staff will be given “COVID-19 passports” to help hospitals redeploy workers during a feared second wave of infection. Bosses at NHS England say the digital passports, which are stored on workers’ phones, have been successful in pilots across the country and are being rolled out “to support the COVID-19 response”. The COVID-19 crisis has triggered a major reorganisation of NHS care, with hospitals now having to plan to restart routine services while at the same time maintain their readiness for any increase in coronavirus cases. The passports will help redeploy staff quickly to where they are needed most. Read full story Source: The Independent, 12 August 2020
  24. News Article
    A healthcare professional is facing a fitness to practise investigation for delaying attending to a COVID-19 positive patient because of inadequate personal protective equipment (PPE), in what may be the first case of its kind. The revelation came from a healthcare regulatory solicitor, Andrea James, who tweeted, “Was expecting it, but still disgusted to have received first #FitnessToPractise case arising from NHS trust disciplining healthcare professional who expressed concern about/delayed attending to a Covid+ patient without PPE (NHS Trust having failed to provide said PPE). For shame.” Doctors and nurses reacted with outrage to the tweet, and the Medical Protection Society issued a strong statement condemning the move. But James said that her client wanted to remain anonymous and declined to identify the profession or the regulator involved. She said that the treatment in question was expected to be an aerosol generating procedure. Rob Hendry, medical director at the Medical Protection Society (MPS), said, “It is appalling enough that healthcare professionals are placed in the position of having to choose between treating patients and keeping themselves and their other patients safe. The stress should not be compounded by the prospect of being brought before a regulatory or disciplinary tribunal. “MPS members who are faced with regulatory or employment action arising from a decision to not see a patient due to lack of PPE can come to us for advice and representation. However, it should not come to this: healthcare workers should not be held personally accountable for decisions or adverse outcomes that are ultimately the result of poor PPE provision.” Read full story Source: BMJ, 12 August 2020
  25. News Article
    Screening women for breast cancer from their 40s rather than their 50s could save lives without adding to the diagnosis of harmless cancers, a UK study has found. The research was based on 160,000 women from England, Scotland and Wales, followed up for around 23 years. Lowering the screening age could save one life per 1,000 women checked, the scientists say. But experts caution there are many other considerations, including cost. Cancer Research UK says it is still "not clear if reducing the breast screening age would give any additional benefit compared to the UK's existing screening programme". The charity says the priority should be getting cancer services "back on track" for women aged 50-70, after disruption caused by the pandemic. Read full story Source: BBC News, 13 August 2020
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