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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    A private company carrying out dermatology services has had its contract suspended by the NHS over concerns about patients safety. DMC Healthcare ran the service which oversaw the care of almost 2,000 patients in north Kent and Medway for more than a year. NHS bosses says those patients may have been harmed and the contract was suspended in June. A helpline has been set up to ensure affected patients are seen by GPs and follow-up treatment can be arranged. Paula Wilkins, Chief Nurse at Kent and Medway Clinical Commissioning Group, said: "In mid-June we suspended most of DMC's dermatology service when we became concerned about patient safety." "I'm very sorry to say, we now know there have been delays in appointments, including for the diagnosis and treatment of cancers, and that has exposed people to the risk of harm." Read full story Source: BBC News, 21 July 2020
  2. Content Article
    Dr Donna Prosser interviews Dr. Albert Wu on the emotional support that we can provide to healthcare workers during this concerning time of the COVID-19 pandemic.
  3. News Article
    Almost half of healthcare workers at some hospitals were infected with COVID-19 during the height of the first wave, the director of a biomedical research centre has told MPs. Sir Paul Nurse, director of the Francis Crick Institute, told MPs today that COVID-19 had infected up to 45% of healthcare workers during ”the height of the pandemic” at some hospitals, according to the centre’s research. Chief medical officer Chris Whitty also told the Health and Social Care Committee that there was more evidence that COVID-19 was transmitted between staff, rather than from patients to staff, and there was “just as much risk as people being in their break rooms than on wards”. Sir Paul told MPs the Francis Crick Institute contacted Downing Street in March and wrote to health secretary Matt Hancock in April to emphasise the importance of regular systematic testing for all healthcare workers as it was “quite clear” that those without symptoms were likely to be transmitting the disease. He said hospital staff “were infecting their colleagues, they were infecting their patients, yet they were not being tested systematically.” Read full story Source: HSJ, 21 July 2020
  4. Content Article
    The COVID-19 pandemic has had an unprecedented impact on the delivery of healthcare services around the globe. This has resulted in important loss of life for our communities, including health professionals that have been exposed to the disease in their workplace. A human factors approach to the recent changes introduced due to the pandemic can help identify how we can minimise the impact of human error in these circumstances. Tejos et al., in Aesthetic Plastic Surgery, present a case study illustrating the application of human factors in the difficult times we are going through at present.
  5. Content Article
    Lea Lane is a US travel writer who hasn’t left her home in over four months, except for medical reasons. Lea gives her own personal account of having coronavirus and the longer term effects it is having on her "Trump has claimed that 99% of cases of COVID-19 are 'totally harmless.' His take is 'live with it.' Many thousands of COVID-19 survivors are unfortunately doing just that, suffering strange, debilitating symptoms that come and go for months after first coming down with the novel virus. Unfortunately we are discovering that the disease can not only be deadly, but chronic — or as sufferers call it, 'long-haul.'
  6. Content Article
    The shared commitment and responsibility uniting everyone within and outside of healthcare during the COVID-19 has been unparalleled. Prior to the pandemic, this type of shared commitment has been discouragingly lacking for other major healthcare concerns such as patient safety. Reasons for this include organisational leaders who are incentivised to focus on activities essential for reimbursement and quality measurement rather than those involving the promotion of safety culture and implementation of systems-based approaches to improve safety, compounded by lack of clear ownership and accountability to solve long-standing safety challenges. The COVID-19 pandemic is leading to several ongoing impacts on the healthcare delivery system, many of which have patient safety implications. We are witnessing negative effects from delays in care from patients not seeking (or unable to seek) healthcare, patients with complex chronic conditions not having ongoing ambulatory care and new types of diagnostic errors. However, we are also witnessing some early short-term positive effects in selected safety areas where the COVID-19 pandemic has provided a new glimmer of hope. Singh et al. explore this further in their article in BMJ Quality & Safety.
  7. News Article
    Doctors who have been shielding during the covid-19 pandemic have said they are worried for their safety when they return to work. From 1 August those who are at high risk of serious illness if they contract covid-19 will no longer be advised to shield in England, Scotland, and Northern Ireland.123 But doctors who have been shielding during the pandemic have expressed concerns about their safety when they return to work, and say they feel forgotten by their employers. Read full story (paywalled) Source: BMJ, 21 July 2020
  8. News Article
    About 3,500 people in England may die within the next five years of one of the four main cancers – breast, lung, oesophageal or bowel – as a result of delays in being diagnosed because of COVID-19, say the researchers in the Lancet Oncology journal. “Our findings demonstrate the impact of the national Covid-19 response, which may cut short the lives of thousands of people with cancer in England over the next five years,” said Dr Ajay Aggarwal from the London School of Hygiene & Tropical Medicine, who led the research. Routine cancer screening was suspended during the lockdown, the authors said. So was the routine referral to hospital outpatient departments of people with symptoms that could be something else but also might possibly be cancer. Only those deemed to need emergency care by the GP or those who go to A&E are being picked up. Inevitably, those are people with more advanced cancers. If cancer is picked up at an earlier stage, successful treatment and survival are much more likely. “Whilst currently attention is being focused on diagnostic pathways where cancer is suspected, the issue is that a significant number of cancers are diagnosed in patients awaiting investigation for symptoms not considered related to be cancer. Therefore we need a whole system approach to avoid the predicted excess deaths,” said Aggarwal. Read full story Source: The Guardian, 20 July 2020
  9. News Article
    A low secure unit for people with learning disabilities and autism has been put into special measures after inspectors found the use of restraint and segregation affected the quality of life for some patients. Cedar House, in Barham near Canterbury, houses up to 39 people and had been rated “good” by the Care Quality Commission early last year. But at an inspection in February this year inspectors rated the service – run by the Huntercombe Group — “inadequate,” saying it was not able to meet the needs of many of the patients at the unit. It was issued with three requirement notices. One patient had been subject to prolonged restraint 65 times between September and February. Each time he was restrained by between two and 19 staff, for an average of nearly two hours. On one occasion, this restraint lasted for eight hours. But the inspectors were told that in the six months before the inspection 29 staff had been injured during these restraints, and the hospital had been trying to refer the patients to a more secure environment. “The impact of this inappropriately placed patient was considerable for both the patients and the hospital,” the report said. “The staff who were regularly involved in restraining the patient were tired and concerned about the welfare and dignity of the patient.” Read full story (paywalled) Source: HSJ, 21 July 2020
  10. News Article
    The coronavirus vaccine candidate being developed by AstraZeneca and Oxford University induces a strong immune response and appears to be safe, according to preliminary trial results. The early stage trial, which involved 1,077 people, has found that the vaccine trains the immune system to produce antibodies and white blood cells capable of fighting the virus. It also causes few side effects. Professor Sarah Gilbert, co-author of the Oxford University study, described the findings as promising but said there “is still much work to be done before we can confirm if our vaccine will help manage the Covid-19 pandemic”. The results came as the UK secured 90 million doses of other promising Covid-19 vaccines, while clinical trials of a new inhaled coronavirus treatment showed it significantly reduced the number of hospitalised patients needing intensive care. Read full story Source: The Independent, 21 July 2020
  11. Content Article
    This book explores patient safety themes in developed, developing and transitioning countries. A foundation premise is the concept of ‘reverse innovation’ as mutual learning from the chapters challenges traditional assumptions about the construction and location of knowledge. hub members can receive a 20% discount. Please email: feedback@pslhub.org to request the discount code.
  12. News Article
    The Parliament and Health Service Ombudsman (PHSO) been working with the NHS and other public service organisations, members of the public and advocacy groups to develop a shared vision for NHS complaint handling. We've called this the Complaint Standards Framework. Now they want to hear from you. Have your say in shaping the future of NHS complaint handling by taking part in their survey. Read the Complaint Standards Framework: Summary of core expectations for NHS organisations and staff
  13. Content Article
    Can we now create a space for interprofessional learning, where trust and respect are born and where clinical skills and clinical reasoning is shared between our professional tribes, asks Lucy Brock in this HSJ article. Lucy works at UCLPartners as the lead for education and simulation. She is also a respiratory physiotherapist and returned to clinical practice to support colleagues on intensive care in March 2020. Regulatory bodies and education systems exist to ensure that patients are surrounded by competent professionals, but the potential of our workforce is unduly limited by their territorial nature and siloed funding. The urgency of a pandemic offered almost no time for creative thinking but we now have a relative reprieve and so a chance to reconsider the limits of professional scope. Can we now create a space for interprofessional learning, where trust and respect are born and where clinical skills and clinical reasoning is shared between our brilliant professional tribes? Might this be key in mobilising a more efficient and agile workforce, better prepared for the next wave?
  14. Content Article
    On Wednesday 8 July 2020 the Independent Medicines and Medical Devices Safety Review published its report First Do No Harm, examining how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. Chaired by Baroness Julia Cumberlege, the review focused on looking at what happened in relation to three medical interventions: hormone pregnancy tests, sodium valproate and pelvic mesh implants. In this blog Patient Safety Learning consider the reports findings in more detail, highlighting the key patient safety themes running through this, which are also found in many other patient safety scandals in the last twenty years. It also looks at what needs to change to prevent these issues recurring and asks whether NHS leaders stick with the current ways of working, make a few improvements, or take this opportunity for transformational change.
  15. Content Article
    Research by the British Medical Association (BMA) concludes that over a million planned operations and treatments as well as over twenty thousand cancer treatments have been cancelled or delayed between April and the end of June this year because of the pandemic. The Association’s research also estimates that more than two and a half million first time outpatient appointments were cancelled during the same time period. This paper coincides with the BMA’s latest survey of 5,905 doctors in England and Wales, asking about the impact of the pandemic on their patients and their working lives. As part of the survey, they were asked if, within the last week, they had treated patients with conditions at a later stage (e.g. cancer, heart disease) than they would normally expect. A little over 40% said that they had. Behind this data are the scores of patients whose routine surgery or procedure has been put aside in the rush to reconfigure the NHS to cope with COVID-19. Even worse, doctors know there are those whose illnesses are far more serious than they were, some now beyond cure. 
  16. Content Article
    Dr Donna Prosser joins Dr Danielle Ofri to discuss the history of medical errors and how they have greatly impacted hospitals during this time of COVID-19.
  17. Content Article
    “Failure to rescue” (FTR) is the failure to prevent a death resulting from a complication of medical care or from a complication of underlying illness or surgery. There is a growing body of evidence that identifies causes and interventions that may improve institutional FTR rates. Why do patients “fail to rescue” after complications in hospital? What clinically relevant interventions have been shown to improve organisational fail to rescue rates? Can successful rescue methods be classified into a simple strategy?
  18. Content Article
    Rehab4Addiction have created resources to help increase understanding and awareness of all aspects of coping with the stress of bereavment and the lockdown. With the current COVID-19 pandemic, many people who live with depression are struggling to stay afloat during mandated or self isolation. The aim is that this resource can be one of many stepping stones for those struggling and their loved ones to better understand their situation and lead them to find a safe and supportive environment, especially during the pandemic.
  19. Event
    As patients and families impacted by harm, we imagine progressive approaches in responding to patient safety incidents – focused on restoring health and repairing trust. We can change how we respond to healthcare harm by shifting the focus away from what happened, towards who has been affected and in what way. This is your opportunity to hear about innovative approaches in Canada, New Zealand, and the United States that appreciate these human impacts. This interactive webinar is hosted by Patients for Patient Safety Canada, the patient-led program of the Canadian Patient Safety Institute (CPSI) and the Canadian arm of the World Health Organization Patients for Patient Safety Global Network. Further information and registration
  20. News Article
    Frontline NHS staff will be given specialist ‘air accident investigation’ style training to help improve the way the health service learns from patient safety incidents. Cranfield University, which has been training air, maritime and rail safety investigators for more than 40 years, is to launch the first intensive course for NHS staff responsible for investigating safety incidents in hospitals. It is part of a growing effort to install a safety science approach to avoidable harm in the NHS, with the service increasingly looking to other industries to adopt new approaches based on the science of human factors and just culture. Traditionally the NHS has focused on simpler investigations that too often miss systemic causes of mistakes and instead target individual nurses and doctors for blame. The new one week intensive course, run in partnership with the charity Baby Lifeline, will start in January and will give students a basic grounding in the science of investigation and using real-life actors and a maternity based scenario, show participants how to get to the real causes of what went wrong. Read full story Source: The Independent, 20 July 2020
  21. News Article
    African American children are three times more likely than their white peers to die after surgery despite arriving at hospitals without serious underlying conditions, the latest evidence of unequal outcomes in health care, according to a study published in the journal Pediatrics, “We know that traditionally, African Americans have poorer health outcomes across every age strata you can look at,” said Olubukola Nafiu, the lead researcher and an anaesthesiologist at Nationwide Children’s Hospital in Columbus, Ohio. “One of the explanations that’s usually given for that, among many, is that African American patients tend to have higher comorbidities. They tend to be sicker.” But his research challenges that explanation, he said, by finding a racial disparity even among otherwise healthy children who came to hospitals for mostly elective surgeries. Out of 172,549 children, 36 died within a month of their operation. But of those children, nearly half were black – even though African Americans made up 11% of the patients overall. Black children had a 0.07% chance of dying after surgery, compared with 0.02% for white children. Postoperative complications and serious adverse events were also more likely among the black patients and they were more likely to require a blood transfusion, experience sepsis, have an unplanned second operation or be unexpectedly intubated. Read full story Source: The Independent, 20 July 2020
  22. News Article
    A GP practice serving one of Greater Manchester’s most deprived communities has been banned from operating for four months after regulators uncovered a catalogue of basic failures - including failing to follow up on a child reporting breathing difficulties for three days. Jarvis Medical Practice in Glodwick has had its registration with the Care Quality Commission (CQC) suspended after ‘serious concerns’ passed to the body led to a snap inspection last month. Inspectors found the practice, based at Glodwick Primary Care Centre, was failing 20 separate standards, many of them relating to patient safety. It noted ‘poor quality’ and conflicting records that were sometimes impossible to properly understand and urgent home visits delayed or not carried out at all. In one case a patient with a lump apparently received no physical examination and was not referred for tests or scans ‘due to Covid-19’. Inspectors also found examples of patients with breathing difficulties, including a child, who were not dealt with for days after they got in touch. In one case no further contact was made for 11 working days, with no explanation provided in the patient's notes. The practice, which serves more than 5,000 patients in the Oldham neighbourhood of Glodwick, has now been suspended by the CQC until October 11. Read full story Source: Manchester Evening News, 17 July 2020
  23. News Article
    Babies are at risk of dying from common treatable infections because NHS staff on maternity wards are not following national guidance and are short-staffed and overworked, an investigation has revealed. The Healthcare Safety Investigation Branch (HSIB), a national safety watchdog, has warned that NHS staff on maternity wards face sometimes conflicting advice on treating women who are positive for a group B streptococcus (GBS) infection. They are also making errors in women’s care because of the pressure of work and a lack of staff, with antibiotics not being administered when they should be. HSIB’s specialist investigators examined 39 safety incidents in which GSB had been identified, and found that the infection had contributed to six baby deaths, six stillbirths and three cases of babies being left with severe brain damage. In its report, the watchdog warned that the problems on maternity wards meant that even in cases where mothers were known to be positive for GBS infection, this wasn’t shared with the mother or noted in the record, resulting in the standard care and antibiotics not being provided. It added: “The identification and escalation of care for babies who show signs of GBS infection after birth was missed. This has resulted in severe brain injury and death for some of the affected babies.” Read full story Source: The Independent, 19 July 2020
  24. News Article
    Dentists are warning of a looming dental and mouth cancer crisis after months of delays and patients being unable to get check-ups and repair work. It comes as surgeries begin to reopen more widely but dentists are still facing significant restrictions on how they can operate, with rooms having to be vacated for an hour after any treatment is done using a drill. For Maezama Malik, who is the principal dentist of her surgery in Croydon, south London, this has caused a big backlog of patients. She said the biggest worry is that a patient might have "something minor that could progress in a few months" without them seeing a dentist. Read full story Source: Sky News, 18 July 2020
  25. Content Article
    Maryanne Mariyaselvam, Clinical Research Fellow at Queen Elizabeth Hospital, presenting at this year's Improving Patient Safety & Care 2020 conference: Safer culture, safer systems, safer patients.
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