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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Animated video explaining why it is important to give feedback about the health and social care you receive in England
  2. Content Article
    Steve Turner and colleagues have been working on ways to put people in charge of their own healthcare. Nowhere is this more important than for people with a variety of conditions or illnesses. Their approach involves people attending a group session on medicines, and then having the option of reviewing their medicines individually in a 3/4-hour session with two health professionals (e.g. a prescriber and a pharmacist). They provide people with their own notes in the form of a written action plan, which they can share with clinicians. Benefits identified to date include improved adherence with medicines; improved quality of life; reduced unnecessary medicines; identification and actions on previously unreported patient safety issues; a potential reduction in ‘bouncing’ referrals, less missing information and fewer unnecessary contacts with services. Steve explains more about Patient Led Clinical Education© and Patient Led Clinical Medicines Review™ in this blog.
  3. Content Article
    NHS England is pushing plans to introduce a ’call before you walk’ model for accident and emergency by winter. But are the health service and the public ready for such a significant shift? HSJ bureau chief and performance lead James Illman tracks the prospects and progress in HSJ's Recovery Watch newsletter.
  4. Content Article
    From bereavement to job losses, to loneliness and relationship breakdown, the psychological strains caused by the coronavirus crisis have affected our mental wellbeing. The psychological impact of the pandemic is an evolving and complex picture that is unlikely to be fully understood for some time. To help navigate the emerging landscape, the Guardian has collected data on five issues faced by the population to measure what life has been like in Britain over the past four months. The Guardian also spoke to charities providing support to people for insight on the trends behind the data.
  5. News Article
    A third of GPs believe it will take up to a year or longer for their practice to return to pre-Covid levels of capacity, even with ‘no future spikes’ of the virus. The data comes from the BMA’s latest COVID-19 tracker survey, which polled almost 2,000 GPs in England and Wales. GPs have previously warned that they are battling a backlog of referrals and patients who have been ‘overlooked’ during the coronavirus crisis. Around 26% of the 1,770 GP respondents said consultations would take between three and 12 months to return to normal when asked how quickly their practice will ‘return to full pre-Covid levels of capacity... assuming there are no future Covid spikes’. And a further 7% of GPs believed it could take ‘longer’ than a year or that consultations would ‘never’ return to pre-Covid levels. Read full story Source: Pulse, 23 July 2020
  6. News Article
    Healthcare staff working at the height of the covid-19 pandemic in England were not properly protected and were forced to work in an unsafe environment, MPs have been told. Appealing before the health and social care committee on 21 July, experts criticised the government and NHS management for their failure to provide staff with sufficient testing and personal protective equipment (PPE). The committee was gathering evidence for its inquiry into the management of the COVID-19 outbreak. Paul Nurse, director of the Francis Crick Institute, said he believed that the failure to implement better testing systems in the early days of the pandemic had contributed significantly to the problems. He said, “At the height of the pandemic, our own research—which backs up what’s been done elsewhere—found that up to 45% of healthcare workers were infected and they were infecting their colleagues and infecting patients, yet they weren’t being tested systematically. “In the healthcare environment we weren’t providing proper protection, and it’s important because it protects the most vulnerable in our society and it protects our healthcare workers. They deserve to work in a safe environment, and some of them are dying because of what they do. They deserve better.” Read full story Source: BMJ, 22 July 2020
  7. Event
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    We're all patients! So, the Patient Safety Movement have created a virtual event on World Patient Safety Day that is relevant to everyone. Please tune in to the digital live streaming event where we will educate the community, entertain you, inspire you with health worker and patient stories, share insights on what the medical systems are learning from COVID-19 and how it impacts your care. All the while we remember those we have lost due to preventable medical harm and celebrate those who have survived. Register
  8. Content Article
    Watch this NHS Confederation webinar which take a closer look at what employers have been doing to support staff wellbeing during the pandemic – and what the future needs to look like in creating the best places to work for everyone.  The webinar was chaired by Danny Mortimer, chief executive of NHS Employers and deputy chief executive of NHS Confederation.
  9. Content Article
    THIS Institute at the University of Cambridge has undertaken a rapid response project to develop an ethical framework for COVID-19 testing for NHS workers. It sought to identify and characterise the ethical considerations likely to be important to the testing programme, while recognising the tension between different values and goals. The project was guided by an expert group and by an online consultation exercise held between 27 May and 8 June 2020 to characterise the range and diversity of views on this topic. The 93 participants in the consultation included NHS workers in clinical and non-clinical roles, NHS senior leaders, policy-makers, and relevant experts. The project report emphasises that getting the COVID-19 swab testing programme for NHS workers right is crucial to support staff and patient safety and broader public health. It also recognises that COVID-19 does not affect all population groups equally. People who are socio-economically disadvantaged or members of Black, Asian and Minority Ethnic (BAME) groups may face distinctive issues in relation to testing.
  10. Content Article
    In 2008, the National Patient Safety Agency (NPSA) issued a Rapid Response Report concerning problems with infusions and sampling from arterial lines. The risk of blood sample contamination from glucose‐containing arterial line infusions was highlighted and changes in arterial line management were recommended. Despite this guidance, errors with arterial line infusions remain common. Gupta and Cook report a case of severe hypoglycaemia and neuroglycopenia caused by glucose contamination of arterial line blood samples. This case occurred despite the implementation of the practice changes recommended in the 2008 NPSA alert. They report an analysis of the factors contributing to this incident using the Yorkshire Contributory Factors Framework. They discuss the nature of the errors that occurred and list the consequent changes in practice implemented in their unit to prevent recurrence of this incident, which go well beyond those recommended by the NPSA in 2008.
  11. News Article
    NHS England and Improvement have launched an independent review into the care and death of a man with learning disabilities, following concerns raised by HSJ. The regulator has appointed Beverley Dawkins to carry out an independent review of the case of Clive Treacy, as part of the learning disability mortality review programme. Clive, who died in 2017, had previously been denied a review under LeDer and, according to emails seen by HSJ, his death was never officially recorded by the programme, which is meant to record all deaths of people with a learning disability. NHS England and Improvement overturned the decision earlier this year after HSJ presented evidence of a series of failures in his care between 2012 and 2017. Today, it was confirmed to us that Ms Dawkins has been commissioned to carry out the review, and that it would review his care throughout his life, as well as his death. Read full story Source: HSJ, 23 July 2020
  12. News Article
    The number of paramedics taking time off with mental health conditions has almost tripled over the last decade, a Guardian analysis has found. In 2019, paramedics took 52,040 days off due to anxiety, stress, depression and other psychiatric illnesses, up from 18,184 in 2011 – an increase of 186%. While the overall number of paramedics has increased slightly over the period, the rate of mental health leave has increased more, resulting in the average number of days taken off per paramedic in a year rising from 2.8 to 5.8. Unison’s head of health, Sara Gorton, said: “Crisis-level staffing has increasingly become the norm within the NHS in recent years, even before the pandemic. Working long hours without breaks, in demanding conditions, it’s no wonder it’s taken a toll on the mental health of workers across the health service. And the coronavirus challenges have piled on more pressure.” Read full story Source: The Guardian, 23 July 2020
  13. News Article
    GP systems will now be updated in 'near-real time' to reveal the result of Covid-19 tests taken by all of their patients. GPs will not need to act on the information, which will be visible on systems whether the patient tested positive or negative. This will apply to all patients where it has been possible to identify the patient's NHS number, NHS Digital said. EMIS Health chief medical officer Shaun O’Hanlon said: "Technology has played a pivotal role in the response to COVID-19 across the board and keeping the medical record up to date with COVID-19 test results means everyone who can share that record has a full picture of the patient’s health, including the patient themselves via Patient Access." "This will not only help day to day patient care, and it will also help on a wider population health level, as data-led insight relies on full and complete medical records as analysts continue to research COVID-19 and its short- and long-term impact on the nation." Read full story Source: Pulse, 20 July 2020
  14. News Article
    South East Coast Ambulance Service NHS Foundation Trust (SECAmb) is the first ambulance service in the country to introduce new pioneering guidance aimed at improving the treatment of spinal injury patients. The guidance includes the ending of the use of neck braces or semi-rigid collars on spinal injury patients. The ground-breaking approach is only currently in place in three other countries – Australia, Norway and Denmark. While collars are often seen as synonymous with spinal care, there is growing evidence that they could cause further harm, while providing little or no benefit. Instead, for ‘standard patients’, spinal precautions will be undertaken with manual in-line stabilisation followed by head blocks, tape and placement on a scoop stretcher secured in a non-rigid vacuum mattress. For a group of ‘non-standard’ patients – which may include older patients, those who are frail or have pre-existing spinal conditions, those with communication difficulties, pregnant patients, young children, bariatric patients or agitated and uncooperative patients – transport on a scoop stretcher is not beneficial. In these cases, a position of comfort approach will be used to minimise spinal motion and a special lanyard will be applied to the patient in order to alert the receiving emergency department of the patient’s status. Soon to be adopted nationally by the Joint Royal Colleges Ambulance Liaison Committee, (JRCALC), SECAmb has been assigned as an ‘early adopter’ while the national guidelines are formalised. Read full story Source: South East Coast Ambulance Service, 15 July 2020
  15. Event
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    The Health Foundation is exploring the pandemic’s implications for health and health inequalities. In this webinar, we share our learning so far, focusing on groups of people who have been particularly affected including young people and Black and minority ethnic groups. We’ll explore what the economic impact of the pandemic means for the wider determinants of health. And, as we move towards post-COVID-19 recovery, we’ll look at what's needed to address health inequalities and to create the conditions for everyone to live a healthy life. Register
  16. News Article
    More than 4 in 10 anaesthetists are not convinced their hospitals would be able to provide safe services should there be a second wave of COVID-19, a new survey has indicated. A survey of members of the Royal College of Anaesthetists (RCOA) showed 44% of respondents were not confident their hospitals would be able to provide safe covid and non-covid services should there be a second surge of infections. The survey also showed levels of mental distress and morale were worsening among anaesthetists – many of whom were drafted into intensive care units during the first wave. Almost two-thirds of respondents (64%) said they had suffered mental distress in the last month due to the pressures faced during the COVID-19 pandemic. Now the college is calling on the NHS to plan intensively for a second covid wave and to identify, train and maintain the skills of cross-specialty “reservists” – including current clinicians, recent retirees and senior trainees — who can support the health service in the event of future surges. One anaesthetist told the RCOA they were “exhausted with constantly having to think about covid and protecting yourself” and “struggling with the realisation that PPE is here to stay for some time.” Another said: “We have burned out our human resource. We need a period of rebuilding or patient harm will result.” Read full story (paywalled) Source: HSJ, 22 July 2020
  17. Content Article
    Between 30 June and 5 July 2020, the Royal College of Anaesthetists conducted a survey to assess its members' views on the current preparedness to restart planned services.  The results found that doctors are not confident their hospitals would cope with a second COVID-19 surge and that more anaesthetists are suffering mental distress than ever before as morale drops.
  18. News Article
    Hospital nurses were told their "lives would be made hell" if they complained over conditions on a coronavirus ward, a union has claimed. Unison has raised a group grievance for 36 employees, most of them nurses, at Nottingham University Hospitals Trust. It said staff on the Queen's Medical Centre ward were not trained properly, faced bullying for raising concerns and denied PPE "as punishment". The trust said the allegations were "very troubling". The union said the staff, which included nurses, senior nurses and healthcare assistants, volunteered to work on the hospital's only ward dealing with end-of-life coronavirus patients. It claimed they were not given any specialist training or counselling for dealing with dying patients and their grieving relatives. An anonymous member of staff described it as "incredibly stressful". Another worker said a board with everyone's record of sickness was put on display in a break room to intimidate staff. Dave Ratchford from Unison said: "This is absolutely shocking stuff. We're talking about a very high-performing team who fell foul of a culture that permits bullying and fails to address it" "Staff were told their lives would be made hell for complaining." Read full story Source: BBC News, 21 July 2020
  19. News Article
    Hospital bosses at scandal-hit Shrewsbury and Telford Hospital Trust were more concerned with reputation management than addressing patient safety concerns in its maternity department, according to a new NHS investigation. Families harmed by poor care at the trust have called for chairman Ben Reid to resign after the report by NHS England revealed how senior figures in the trust, including the former chief executive, tried to soften a report into maternity services that raised serious concerns over safety. The Royal College of Obstetricians and Gynaecologists (RCOG) report was not published until after the college had agreed to an “unprecedented” addendum report 12 months after its inspection in 2017, that presented the trust in a more positive light. When the final report was made public in July 2018 the addendum was placed at the front of the report. The original RCOG report warned: “Neonatal and perinatal mortality rates will not improve until areas of poor / substandard care are addressed.” Read full story Source: The Independent, 22 July 2020
  20. News Article
    Research into patient safety across Europe, led by Northumbria University, has received international acclaim. The SLIPPS (Shared Learning from Practice to improve Patient Safety) project is a major EU-funded project led by Professor Alison Steven, a Reader in Health Professions Education at Northumbria University. It seeks to improve European patient safety and education across a range of clinical settings. Errors, mishaps and misunderstandings are common and around one in 10 patients suffer avoidable harm. These incidents impact upon patients, their families, health care organisations, staff and students. SLIPPS is responding to the challenge to improve patient safety education. Professor Steven has a longstanding interest in the use of education to raise standards of care and ensure patient safety. Considering the rapid spread of COVID-19, she says improving patient safety and standards of care across Europe and beyond, has never been more important. “Patient safety is paramount in these extreme circumstances,” said Professor Steven. “The SLIPPS project is unique in that it taps into students’ experiences. These students on practice placements have the potential to offer fresh perspectives on clinical practices, and with so many final-year students treating patients on the front line during this global pandemic, their current views on patient safety are more important than ever.” The project utilises real-life experiences and students’ reflections on them as the basis for a range of educational resources which feed into an open access virtual learning centre for international, multi-professional learning about patient safety. Read full story Source: Northumbria University Newcastle, 20 July 2020
  21. News Article
    Hundreds more cases of potentially avoidable baby deaths, stillbirths and brain damage have emerged at an NHS trust, raising concerns about a possible cover-up of the true extent of one the biggest scandals in the health service’s history. The additional 496 cases raise further serious concerns about maternity care at Shrewsbury and Telford hospital NHS trust since 2000. The cases involving stillbirths, neonatal deaths or baby brain damage, as well as a small number of maternal deaths, have been passed to an independent maternity review, led by the midwifery expert Donna Ockenden. They bring the total number of cases being examined to 1,862. They will also be passed to West Mercia police, which last month launched a criminal investigation into the trust’s maternity services. Detectives are trying to establish whether there is enough evidence to bring charges of corporate manslaughter against the trust or individual manslaughter charges against staff involved. The extra 496 cases had not emerged until now because an “open book” initiative led by the NHS in 2018 asked only for digital records of cases identified as a cause for serious concerns. The vast majority of the 496 further cases were recorded only in paper documents. Read full story Source: The Guardian, 21 July 2020
  22. Content Article
    Cognition is the mental process of knowing, including awareness, perception, reasoning and judgement, and is distinct from emotion and volition. Cognitive processes include mental shortcuts, which speed up decision making. However, cognitive bias occurs when the shortcut causes inferences about other people and/or situations to be drawn in an illogical fashion. There is a tendency to display bias in judgements that are made in everyday life, indeed this is a natural element of the human psyche. Jumping to a conclusion, tunnel vision, only seeing what is expected/wanted, being influenced by the views of others, all are recognisable behaviours. However, whilst such biases may be commonplace and part of human nature, it is essential to guard against these in forensic science, where many processes require subjective evaluations and interpretations. The consequences of cognitive bias may be far-reaching; investigators may be influenced to follow a particular line of enquiry or interpretation of a finding that may be incomplete, or even wrong. Simply because there is a risk of a cognitive bias does not imply that it occurs. The problem is that as it is a subconscious bias it is unlikely that an individual will know either way and therefore it is wise that all practitioners understand the issue and take proportionate steps to mitigate against it.
  23. Content Article
    The Forensic Science Regulator publishes lessons that can be learnt from quality failings.
  24. Content Article
    The review by the Cabinet Office's Major Projects Authority (MPA) on the NHS National Programme for IT.
  25. Content Article
    This study from Morris et al. aimed to review the literature describing and quantifying time lags in the health research translation process. Papers were included in the review if they quantified time lags in the development of health interventions. The study identified 23 papers. Few were comparable as different studies use different measures, of different things, at different time points.
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