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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The Framework sets out a single set of standards for staff to follow and provides standards for leaders to help them capture and act on the learning from complaints.  This is a draft Framework developed with partners across the health sector and PHSO are keen to hear people's views on the draft so they can improve it. The online survey can be found here. 
  2. News Article
    Inpatient mortality among people receiving non-invasive ventilation (NIV) has decreased for the first time since 2010, falling from 34% in 2013 to 26% in 2019, figures released by the British Thoracic Society show. The annual National Adult Non-Invasive Ventilation audit, which began in 2010, reported “substantial improvements in processes of care and patient outcomes” in 2019 when compared with previous years. “Some improvement in overall mortality may be attributed to improved patient selection,” it said. “Mortality outcomes were lower for each diagnostic category, and most notably for patients with COPD [chronic obstructive pulmonary disease] and obesity-related respiratory failure.” Read full story (paywalled) Source: BMJ, 10 July 2020
  3. News Article
    Pharmacies are warning people are at risk of not getting the flu jab unless an urgent decision is made over the winter vaccination programme. The Company Chemists’ Association, which represents large pharmacy groups, told HSJ the government and NHS England need to “urgently” clarify how many people it wants vaccinated for flu this year, as well as making changes to regulations. An expanded and successful winter vaccine programme is seen as key to avoiding potentially catastrophic demand for hospital beds, with flu demand coinciding with covid-19 surges. Malcolm Harrison, chief executive, said: “We need decisions made now. We have an ongoing dialogue with NHS England but they seem to be waiting on secretary of state’s decision on which groups need vaccinating. That is something [the health secretary, Matt Hancock] needs to make a decision about very, very soon.” Read full story (paywalled) Source: HSJ, 10 July 2020
  4. News Article
    Relatives of care home residents with dementia should be treated as key workers, leading charities say. In a letter to the health secretary, they write that the care given by family members is "essential" to residents' mental and physical health. They argue the current limits on visitors have had "damaging consequences" and they want visits to resume safely, with relatives given the same access to care homes and coronavirus testing as staff. Signed by the bosses of leading charities including Dementia UK and the Alzheimer's Society, the letter calls on the government to "urgently" address what it calls the "hidden catastrophe" happening in care homes. The charities say that this "enforced separation" has caused a "deterioration" in residents' mental and physical health, particularly for those living with dementia - who make up more than 70% of the population of care homes. Read full story Source: BBC News, 9 July 2020
  5. News Article
    Daniel Mason was born half a century ago without hands, with missing toes, a malformed mouth and impaired vision. From an early age, he and his family had to deal with people asking about his disabilities. The impact on his life has been considerable. Daniel’s mother Daphne long suspected the cause of his problems was a powerful hormone tablet called Primodos that was given to women to determine whether they were pregnant. But when she raised her concerns with doctors, they were dismissed. Now, at last, Daphne has been vindicated with official confirmation this week that her fears were right, in the landmark review by Baroness Cumberlege into three separate health scandals that has exposed a litany of shameful failings by the NHS, regulatory authorities and private hospitals. This damning report shows again the danger of placing a public service on a pedestal, with politicians happy to spout platitudes but scared to tackle systemic problems or confront the medical establishment. But how many more of these inquiries must be held? How many more disturbing reports and reviews must be written? How many more times must we listen to ministerial apologies to betrayed patients? How much more must we hear of ‘lessons being learned’ when clearly they are largely ignored? Read full story Source: Mail Online, 9 July 2020
  6. Content Article
    User-testing and subsequent modification of clinical guidelines increases health professionals’ information retrieval and comprehension, but no study has investigated whether this results in safer care. Jones et al. compared the frequency of medication errors when administering an intravenous medicine using the current National Health Service Injectable Medicines Guide (IMG) versus an IMG version revised with user-testing. Participants were on-duty nurses/midwives who regularly prepared intravenous medicines. Using a training manikin in their clinical area, participants administered a voriconazole infusion, a high-risk medicine requiring several steps to prepare. They were randomised to use current IMG guidelines or IMG guidelines revised with user-testing.
  7. Content Article
    This is the first report from the patient experience programme, Being A Patient, which explores what it means to be a patient and how understanding of the patient experience is used by the health service.
  8. Content Article
    The contents of this book are based on the experiences of: NHS patients who have experienced avoidable harm, and associated cover-ups. NHS staff who have suffered detriment for speaking out on behalf of the above. The author's own experience as an employee of St George's hospital, Tooting, and doing locum work at hospitals in London and the Home Counties. Written from the perspective of an NHS Operating Department Practitioner, and whistleblower, NHS Dirty Secrets describes how the NHS cover-up culture is a risk to patient safety, and how employment and promotion practices are skewed in favour of those most likely to support the NHS cover-up culture. The NHS cover-up culture, itself, is decomposed and analysed, with examples given as to the methods used to support the hiding of issues, such as patient deaths, from public scrutiny.
  9. News Article
    Far fewer people are having surgery or cancer treatment because COVID-19 has disrupted NHS services so dramatically, and those who do are facing the longest waits on record. NHS figures reveal huge falls in the number of patients who have been going into hospital for a range of vital care in England since the pandemic began in March, prompting fears that their health will have worsened because diseases and conditions went untreated. Patients have been unable to access a wide range of normal care since non-COVID-19 services were suspended in hospitals in March so the NHS could focus on treating the disease. Many patients were also afraid to go into hospital in case they became infected, which contributed to a fall in treatment volumes. Tim Gardner, a senior policy fellow at the Health Foundation thinktank, said: “The dramatic falls in people visiting A&E, urgent referrals for suspected cancer and routine hospital procedures during lockdown are all growing evidence that more people are going without the care they need for serious health conditions." “Early diagnosis and prompt treatment of cancer is crucial to saving lives, and delays in referrals and treatment during the pandemic are likely to mean more people are diagnosed later when their illness is further advanced and harder to treat.” Read full story Source: Guardian, 9 July 2020
  10. Event
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    The number one focus in the world right now is health care and the critical need to bring greater efficiency to treating patients. During the COVID-19 pandemic, vast amounts of information are rapidly cross-crossing the globe. Governments, health systems, and research communities in the European region are looking to learn as much as possible from each other, as quickly as possible, about the nature of COVID-19 and the most effective interventions for preventing and treating it. We cannot afford to ignore the clear signs pointing to a new future of increased care needs, labour shortages, and operational strain. From COVID-19 to general routine care, we must act now to ensure that no patient waits for the care they need. For health care professionals looking to structure their leadership plans around lessons learned in the field comes the 'Hospital Flow in the UK: During and Beyond COVID-19'. In this online course from the Institute for Healthcare Improvement (IHI), health care leaders address challenges and share successes, best practices, and strategies to effectively advance the long-term goal of improving community health in a post-COVID world. Experts will discuss noteworthy global challenges and responses to COVID-19, specifically focusing on efforts in the United Kingdom (UK) to monitor and quickly improve treatment for patients across the care continuum. Further information and registration
  11. News Article
    The Medicines and Healthcare products Regulatory Agency (MHRA) has published its response to the Independent Medicines and Medical Devices Safety Review. In its response, the MHRA said: “Today’s publication of the Independent Medicines and Medical Devices Safety Review is of profound importance for the MHRA, since the safety of the public is our first priority." "We therefore take this report and its findings extremely seriously. Throughout the Review’s work we have listened intently to the many distressing experiences of women and their families. We will now carefully study the findings and recommendations of the Report. We recognise that patient safety must be continually protected and that many of the major changes recommended by the Review cannot wait. We are therefore making changes without delay to ensure that we listen to patients and involve them in every aspect of our work. We are already taking steps to strengthen our collaboration with all bodies in the healthcare system and will strive to ensure that, working with these other bodies, the safety changes we advise are embedded without delay in clinical practice. We wholeheartedly commit to demonstrating to those patients and families who have shared their experiences during the Review, and anyone else who has suffered, that we have learned from them and are changing and improving because of what they have told us. We are determined to put patients and the public at the heart of everything we do." Read full statement Source: GOV.UK, 8 July 2020
  12. Content Article
    This Review was announced in the House of Commons on 21 February 2018 by Jeremy Hunt, the then Secretary of State for Health and Social Care. Its purpose is to examine how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices and to consider how to respond to them more quickly and effectively in the future. The Review was asked to investigate what had happened in respect of two medications and one medical device: hormone pregnancy tests (HPTs) – tests, such as Primodos, which were withdrawn from the market in the late 1970s and which are thought to be associated with birth defects and miscarriages; sodium valproate – an effective anti-epileptic drug which causes physical malformations, autism and developmental delay in many children when it is taken by their mothers during pregnancy; and pelvic mesh implants – used in the surgical repair of pelvic organ prolapse and to manage stress urinary incontinence. Its use has been linked to crippling, life- changing, complications; and to make recommendations for the future. The Review was prompted by patient-led campaigns that have run for years and, in the cases of valproate and Primodos over decades, drawing active support from their respective All-Party Parliamentary Groups and the media. 
  13. News Article
    Patients with respiratory disease have been overlooked during the COVID-19 pandemic, with the NHS storing up problems for the winter months, a group of experts including the Royal College of General Practitioners (RCGP) has warned. Analysis by the 34-member Taskforce for Lung Health showed that referrals for lung conditions fell by 70% in April, with two-in-five (39%) of CCGs seeing no appointment bookings for respiratory conditions for the whole of May. On average, the group calculated a weekly average of 3,399 lung patients missing out on urgent and routine referrals during the COVID-19 lockdown, amounting to a total of at least 34,780 people, based on NHS England data. This was blamed in part on a general reduction in routine procedures during the pandemic, which will have affected all disease areas, but also the limitations on clinicians including GPs to carry out spirometry due to the risk of COVID-19 infection spread. But the taskforce - which includes the RCGP and the Primary Care Respiratory Society, as well as the Royal College of Physicians and Asthma UK - is now calling on NHS England to urgently restore services to pre-pandemic levels to tackle the backlog of lung patients requiring support. It said that failure to do so risked causing the premature death of patients who require urgent diagnosis as well as overwhelming the NHS during the winter season, when respiratory symptoms worsen. Read full story Source: Pulse, 9 July 2020
  14. Content Article
    The coronavirus (Covid-19) pandemic will leave a deep and lasting scar on the mental health of millions in this country. The devastating loss of life, the impact of lockdown and loneliness, and the inevitable recession that lies ahead will affect all of us. Prioritising mental health has never been more critical than it is now. New mental health problems have developed as a result of the pandemic, and existing mental health problems have gotten worse. To understand how we can best support people during this uncertain time, Mind carried out research to understand the experiences of people with pre-existing mental health problems, the challenges that they are facing, the coping strategies that they are using, and the support they would like to receive.
  15. Content Article
    This interactive webinar was part of the world tour series designed by the World Health Organization's Patients for Patient Safety (PFPS) Global Network and hosted by Patients for Patient Safety Canada, the patient-led program of the Canadian Patient Safety Institute, a WHO Collaborating Centre on Patient Safety and Patient Engagement. Watch on demand and download slides from the webinar.
  16. News Article
    Health leaders have called for the routine recording of ethnicity and faith during the registration of deaths to help fight COVID-19, but the government appears to have rejected the idea. Leaders at West Yorkshire and Harrogate Health and Care Partnership, the second largest integrated care system in England, wrote to registrar general Abi Tierney last month and said the lack of routine collection and analysis of this data “means there is a structural barrier to understanding of inequalities in mortality”. The Home Office replied and said it is considering “a range of reliable and proportionate ways to collect the necessary information”. But HSJ understands the Home Office has indicated no immediate action will be taken on the issue. The letter said: “This absence has undoubtedly led to delays in identifying the inequalities of COVID-19 mortality and means that we remain unclear about the disparities in deaths outside of hospital. These delays have risked contributing to further loss of life in our places in recent weeks, as we have not had robust data to enable us to address impacts at sufficient pace as we have been dealing with this crisis.” Read full story (paywalled) Source: HSJ, 8 July 2020
  17. News Article
    Former health secretary Jeremy Hunt has warned ministers not to let the Cumberlege review “gather dust on a shelf”. The chair of the Commons Health and Social Care Committee told The Independent it was vital action was taken to implement the recommendations. Mr Hunt, who made patient safety a key focus of his tenure as health secretary, backed the idea of an independent patient safety commissioner that would be outside the NHS and have powers to advocate for patient issues. Mr Hunt said: “This report should be a powerful wake-up call that our healthcare system is still too closed, defensive and focused on blame rather than learning lessons. It’s truly harrowing to hear of all the women and families who live with permanent anguish because of these medicines and devices, and it has clearly taken too long for their voices to be heard.” “The NHS is one of the safest health systems in the world, and we’re all rightly in awe of our frontline heroes. But in healthcare getting it right ‘most’ times isn’t good enough because the exceptions wreak lifelong devastation on families. So we must not allow this seminal report to gather dust on a shelf: lessons must be learnt once and for all.” Read full story Source: The Independent, 8 July 2020
  18. News Article
    CAP-COVID are conducting essential research on how the COVID-19 pandemic affects pregnant women and their babies. If you are a pregnant woman at any stage of pregnancy, you can take part in the study. This includes whether you have just had a positive pregnancy test (even if you are unsure what to do about your pregnancy), whether you are in the middle of pregnancy, or you are about to have your baby. Take part
  19. Content Article
    The NHS has been fighting for our lives for the last few weeks and months. Throwing all its resources at the COVID-19 pandemic. The millions of health and care workers involved have been magnificent and we must resource them better for the future. And it’s been up to us, the general public, how far and how fast the virus spreads. There will still be a vital role for us when this pandemic is over because the NHS can’t by itself deal with many of today’s major health problems such as loneliness, stress, obesity, poverty and addictions. It can only react, doing the repairs but not dealing with the underlying causes. There are people all over the country who are tackling these causes in their homes, workplaces and communities. People like the Berkshire teachers working with children excluded from school, the unemployed men in Salford improving their community; and the bankers tackling mental health in the City. They are not just preventing disease but creating health. And they take pressure off the NHS, so it is always there when we need it. Health is made at home challenges us to set aside our normal assumptions and take off our NHS spectacles to see the world differently and take control of our health. And it calls for a new partnership between the NHS, government and the general public to build a healthy and health creating society.
  20. News Article
    Urgent cancer referrals were "inappropriately" rejected by hospitals during the coronavirus lockdown without tests being carried out, GPs have said. Cancer Research UK said the findings from a survey of more than 1,000 GPs were "alarming", warning that patients whose lives may be at risk were being left "in limbo". Family doctors were surveyed in June and asked what had happened to patients they had referred to hospitals for tests in the month to that point because cancer was suspected. A quarter of GPs said urgent referrals had been inappropriately turned down by hospitals more often than had been the case before the pandemic. Four in 10 said that, when tests were refused, patients had been left without proper checks to see whether their case could safely be left without investigation. Read full story (paywalled) Source: The Telegraph, 8 July 2020
  21. News Article
    Many lives have been ruined because officials failed to hear the concerns of women given drugs and procedures that caused them or their babies considerable harm, says a review. More than 700 women and their families shared "harrowing" details about vaginal mesh, Primodos and an epilepsy drug called sodium valproate. Too often worries and complaints were dismissed as "women's problems". It says arrogant attitudes left women traumatised, intimidated and confused. June Wray, 73 and from Newcastle, experienced chronic pain after having a vaginal mesh procedure in 2009. "Sometimes the pain is so severe, I feel like I will pass out. But when I told GPs and surgeons, they didn't believe me. They just looked at me like I was mad." The chairwoman of the highly critical review, Baroness Julia Cumberlege, said the families affected deserved a fulsome apology from the government. She said: "I have conducted many reviews and inquiries over the years, but I have never encountered anything like this; the intensity of suffering experienced by so many families, and the fact that they have endured it for decades. Much of this suffering was entirely avoidable, caused and compounded by failings in the health system itself." Read full story Source: BBC News, 8 July 2020
  22. News Article
    The Public Accounts Committee has given the Department of Health and Social Care two months to report back with a plan to ensure personal protective equipment (PPE) provision during a second COVID-19 spike. The influential group of MPs said they were 'extremely concerned' by PPE shortages faced by NHS and care workers during the first wave of the pandemic in the UK. According to the DHSC it never ran out of stock of PPE but rather Covid-19 had 'put supply chains and distribution networks under unprecedented strain', posing challenges with ensuring the right equipment was at the right place at the right time. BMA council chair Dr Chaand Nagpaul said: 'We may be past the first peak of this virus, but we should be under no illusion that the demand for PPE is over – especially as the NHS begins to manage the huge backlog of demand caused by the pandemic, all under tighter infection control measures.' In light of the threat of a second wave of Covid-19 doctors and colleagues 'need cast-iron guarantees from Government that the failures of the past months will not be repeated, that there will be enough of the right PPE and that it will be properly tested, quality-controlled and safe to use', Dr Nagpaul added. Read full story Source: Pulse, 8 July 2020
  23. News Article
    The Care Quality Commission (CQC) staged an unannounced inspection after two deaths at a mental health unit which it had condemned as “not fit for purpose.” Two earlier CQC inspections – in 2017 and 2018 – had also been prompted by deaths on the same unit. The CQC visited the Abraham Cowley Unit, which is at St Peter’s Hospital in Chertsey and run by Surrey and Borders Partnership Foundation Trust, on 26 June. Two inpatients died in April and May on an inpatient ward for working age men. The deaths both involved “ligature harm” and have led to the trust reviewing its ligature minimisation strategy, according to board papers. Read full story (paywalled) Source: HSJ, 8 July 2020
  24. Content Article
    Lesley Flatley, reflects on some of the challenges and key learnings from leading in isolation, as a manager in an independent care home, during the pandemic. "Our experiences of the pandemic so far have been extremely challenging, but we must continue to improve and build on new ways of working to ensure that staff and residents are supported."
  25. Event
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    NHS leaders are concerned that the suspension of normal services due to the COVID-19 pandemic, along with the fact that people have been isolating and following social distancing measures, may have led to potentially thousands more cases of CVD being undiagnosed. The NHS Long Term Plan has detailed an ambition to improve early detection and treatment of CVD, however, there are still too many people living with high-risk conditions such as Atrial Fibrillation. Progress has been made on identification and diagnosis through the use of digital technology. These digital tools are set to become even more important and widespread in their use as we move past the peak of the pandemic and into the recovery phase. This free webinar chaired by National Clinical Director for CVD Prevention Dr. Shahed Ahmad, will set out how the Long Term Plan’s ambitions for CVD prevention might now be achieved as we enter a ‘new normal’ healthcare landscape. Register
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