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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Almost half a million people are waiting at least six weeks for tests which could diagnose cancer – up from just 30,000 before lockdown, new analysis shows. Ministers have been urged to urgently bring forward plans to tackle the backlog of patients waiting for care, with calls for weekly testing of staff to keep coronavirus infections off the wards. Cancer charities fear there will be an extra 18,000 deaths a year because those with symptoms are not receiving prompt diagnosis and treatment. Read full story (paywalled) Source: The Telegraph, 23 June 2020
  2. News Article
    Tens of thousands of people will need to be recalled to hospital after a serious OVID-19 infection to check if they have been left with permanent lung damage, doctors have told the BBC. Experts are concerned a significant proportion could be left with lung scarring, known as pulmonary fibrosis. The condition is irreversible and symptoms can include severe shortness of breath, coughing and fatigue. Research into the prevalence of lung damage caused by COVID-19 is still at a very early stage. It's thought those with a mild form of the disease are unlikely to suffer permanent damage. But those in hospital, and particularly those in intensive care or with a severe infection, are more vulnerable to complications. In a study from China, published in March, 66 of 70 patients still had some level of lung damage after being discharged from hospital. Radiologists in the UK say, based on the early results of follow-up scans, they are concerned about the long term-effects of a serious infection. Prof Gisli Jenkins, of the National Institute for Health Research, is running assessment clinics for those discharged from hospital with COVID-19. He said: "My real concern is that never before in our lifetime have so many people been subject to the same lung injury at the same time." NHS England has said it is planning to open a number of specialist COVID-19 rehabilitation centres to help patients recover from long-term effects, including possible lung damage. Read full story Source: BBC News, 24 June 2020
  3. News Article
    An independent provider’s NHS contract has been suspended, and a harm review is to be carried out on patients who have faced a long wait. Kent and Medway Clinical Commissioning Group suspended DMC Healthcare’s contract to provide dermatology services in north Kent “to ensure patient safety” on Friday. It said it had showing some patients had been on waiting lists longer than they should have been. It is unable to say how many patients are likely to be involved in the harm review, but it is expected to focus on those who have waited longer than they should or where harm is suspected. Read full story (paywalled) Source: HSJ, 24 June 2020
  4. News Article
    Health leaders are calling for an urgent review to determine whether the UK is properly prepared for the "real risk" of a second wave of coronavirus. In an open letter published in the BMJ, ministers were warned that urgent action would be needed to prevent further loss of life. The presidents of the Royal Colleges of Surgeons, Nursing, Physicians, and GPs all signed the letter. It comes after Boris Johnson announced sweeping changes to England's lockdown. Following the prime minister's announcement, health leaders called for a "rapid and forward-looking assessment" of how prepared the UK would be for a new outbreak of the virus. "While the future shape of the pandemic in the UK is hard to predict, the available evidence indicates that local flare-ups are increasingly likely and a second wave a real risk," they wrote in the letter. "Many elements of the infrastructure needed to contain the virus are beginning to be put in place, but substantial challenges remain." The authors of the letter, also signed by the chair of the British Medical Association, urged ministers to set up a cross-party group with a "constructive, non-partisan, four nations approach", tasked with developing practical recommendations. "The review should not be about looking back or attributing blame," they said, and instead should focus on "areas of weakness where action is needed urgently to prevent further loss of life and restore the economy as fully and as quickly as possible". Read full story Source: BBC News, 24 June 2020
  5. Content Article
    'Implications of COVID-19 for the safe management of general dental practice: a practical guide' supports dental professionals to take a risk-based and evidence-based approach to providing safe general dental care, whatever the national threat level. 
  6. Event
    until
    Hosted by Govconnect, Helen Hughes, Jamie Munro, Stewart Munro and Dylan Goaten. COVID-19 exposed the shortfall of some vital equipment in the NHS; ventilators were the headline product. However, volumetric infusion pumps were another example of equipment being transferred to ICU, leading to a severe shortage for normal requirements. Hospitals, already poorly equipped with adequate pumps, urgently required reliable methods of monitoring IV infusions. When the severity of the pandemic became apparent earlier this year, it triggered somewhat of a panic in the NHS. Normal procurement practice was suspended. Overnight procurement barriers preventing the adoption of new products and innovations were lifted and funding available. The webinar will present a case study from West Suffolk Hospital who will describe their experiences with the shortage of volumetric pumps and how Pentland Medical were able to assist with the Monidrop device. Feedback from the Nursing team who have implemented Monidrop into their everyday practice will also feature. Patient Safety Learning's Helen Hughes will be presenting Further information and registration
  7. News Article
    NHS England and Improvement have announced changes to the NHS’s complaints process during the coronavirus emergency. Individual NHS organisations are being told to ensure complaints are still taken, and monitored for patient safety issues. However, NHS organisations have been given latitude over whether they launch full investigation processes in the short term, and being advised to ‘manage expectations’ about investigations being launched. Complaints that are logged will remain open until further notice. The advice to NHS providers also says that where patients have been waiting over six months for a resolution to their complaint, consideration should be given now to making an effort to see if the complaint can be resolved. NHS England and Improvement have announced that they will be advising NHS bodies to end their 'pause' in complaints handling from 1 July onwards. Similarly, the Parliamentary and Health Service Ombudsman (PHSO) reduced its complaints-handling activity during the emergency period. It is not accepting new complaints, and its helpline is temporarily closed. PHSO has announced that it will recommence work on existing complaints, and begin accepting new ones from 1 July. Read full story Source: The Patients Association, 15 June 2020
  8. Content Article
    The Oxford Academic Health Science Network (AHSN) has published their 2019/2020 report highlighting their achievements, including details of key projects, key national programmes and economic growth.
  9. Content Article
    Presentation from Steve Turner at a NICE Associates Meeting on over prescribing of medication to patients with learning disabilities and reasonable adjustments. He highlights the death of Oliver McGowan and the lessons learnt.
  10. News Article
    Over 90 civil society groups and individual signatories are calling on all public authorities and private sector organisations to protect those who expose harms, abuses and serious wrongdoing during the COVID-19 crisis. Since the beginning of the COVID-19 emergency, worrying reports concerning hospitals and public authorities retaliating against healthcare professionals for speaking out about the realities of COVID-19 have emerged worldwide, from China to the United States. Transparency International urges decision-makers at the highest level to resist the temptation to control the flow of information and instead offer assurances to individuals who witness corruption and wrongdoing to blow the whistle. Marie Terracol, Whistleblowing Programme Coordinator at Transparency International said: “The need for transparency and integrity, heightened in this time of crisis where abuses can cost lives, illustrates the essential role of those who speak up in the public interest." “National governments, public institutions and companies should listen to workers and citizens who come forward and report abuses they witness and protect them from retaliation, including in countries which still do not offer robust legal whistleblower protection. If people feel they can safely make a difference by speaking up, more instances of abuses will be prevented and addressed, and lives might be saved.” Read full story Source: Transparency International. 22 April 2020
  11. News Article
    A new risk tool could be used to identify those most at threat from COVID-19, so GPs can give patients tailored advice, health officials have said. Scientists at Oxford University are working on a clinical risk prediction model, which aims to give individuals more precise information about the likely impact of the disease on them, instead of a blanket approach. Health officials said the plans aimed to allow “very individualised discussions” between patients and their doctors, in the event of future outbreaks, particularly as winter approaches. Read full story (paywalled) Source: The Telegraph, 23 June 2020
  12. News Article
    Discharging patients into care homes in England in early April, when the number of coronavirus cases was rapidly increasing, was neither reckless nor wrong, the Department of Health and Social Care’s (DHSC) most senior civil servant has claimed. Faced with aggressive questioning from MPs on the powerful public accounts committee on Monday, Sir Chris Wormald, permanent secretary at the DHSC, said the guidance for discharge was correct based on the information available at the time. Conservative MP Sir Geoffrey Clifton-Brown said to Wormald: “You were discharging them from hospital into care homes when care homes were already in dire trouble, some of the most vulnerable people in society, the testing wasn’t available, PPE [personal protective equipment] wasn’t available, the training wasn’t available. Wasn’t this a pretty reckless policy by the government?” Wormald replied: “We don’t believe that. Now, as Prof [Stephen] Powis [national medical director of NHS England] described, at this point Covid was not considered to be widespread in the community.” A clearly frustrated Clifton-Brown interrupted him saying there were already 1,000 care homes with coronavirus cases at the beginning of April. He also questioned why detailed advice in relation to coronavirus for the social care sector had not been issued until 15 April, almost a month after the equivalent information was provided to the NHS. Read full story Source: The Guardian, 23 June 2020
  13. News Article
    The 2.2 million people who have been self-isolating in England during the pandemic will no longer need to shield from 1 August. From 6 July, they will be able to meet up outdoors, in a group, with up to five others and form 'support bubbles' with other households. The measures can be eased because infection rates are falling, the government says. Among the list of people who should be shielding are solid organ transplant recipients, cancer patients undergoing chemotherapy, pregnant women with heart disease and people with severe respiratory conditions such as cystic fibrosis and severe asthma. The government says it has worked with clinicians, GPs, charities, the voluntary sector and patient groups on the changes, but some charities are criticising the relaxing of the advice, saying many of the people they support do not feel it is safe to stop shielding. Read full story Source: BBC News, 23 June 2020
  14. Content Article
    The COVID-19 pandemic has uncovered serious gaps in the healthcare systems of many nations. In particular, it exposes a fragmented global governance system that does not have the structures to coordinate the pooling and sharing of resources needed to combat pandemics. Since the early days of the pandemic, medical protectionism has emerged as nations scrambled for their own stocks of personal protective equipment and ventilators. COVID-19 vaccines could be the next example. Already there is a danger of a vaccine bidding war, with governments competing for a limited number of doses, well before a vaccine even reaches the market. It is imperative that more governments and pharmaceutical companies agree to shoulder the costs of vaccine research and manufacturing, and to share data and technologies. They need to commit to WHO allocation guidelines and cooperate globally to distribute vaccines fairly to those at greatest risk. A pandemic vaccine needs strong global governance behind it.
  15. Content Article
    Mary Robinson, Chair of the All Party Parliamentary Group for Whistleblowing, has written to Health and Social Care Secretary Matt Hannock. The APPG for Whistleblowing has been examining evidence surrounding the issues facing whistleblowers over the last two years, and more recently during the coronavirus pandemic. The APPG has concluded that the crisis has exposed some terminal failings within the existing whisleblowing framework, particularly around transparency and accountability.
  16. Event
    until
    This event celebrates the launch of the Chartered Institute of Ergonomics and Human Factors (CIEHF)’s new White Paper on ‘Learning from Adverse Events’. There has been enormous progress in safety over the years, yet the frequency with which major adverse events continue to occur across nearly every sector of the economy and the extent of the pain, suffering, loss and hardship that arises, suggests a fundamental weakness in the ability of developed societies to adequately learn from the things that go wrong, and to take action that’s effective in preventing recurrence of similar events. The 48-page document is designed to: 1. Help organisations understand a human factors perspective to investigating and learning from adverse events. 2. Provide key principles organisations can apply to capture the human contribution to adverse events. Who should attend? Anyone in any industry or service responsible for managing significant risk, and anyone involved in investigating incidents and adverse events. And of course, anyone interested in organisational learning. Further information and registration
  17. Content Article
    There is clear evidence that COVID-19 does not affect all population groups equally. Many analyses have shown that older age, ethnicity, male sex and geographical area, for example, are associated with the risk of getting the infection, experiencing more severe symptoms and higher rates of death. This work has been commissioned by the Chief Medical Officer for England to understand the extent that ethnicity impacts upon risk and outcomes. The Public Health England (PHE) review of disparities in the risk and outcomes of COVID-19 shows that there is an association between belonging to some ethnic groups and the likelihood of testing positive and dying with COVID-19. Genetics were not included in the scope of the review.
  18. News Article
    Doctors have warned that a “culture of fear” in the NHS may prevent life-saving lessons being learned about COVID-19 after a leading hospital consultant emailed scores of staff saying those responsible for “leaks” would be found and fired. Dr Daniel Martin OBE, head of intensive care for serious infectious diseases at the Royal Free hospital, emailed a report to colleagues at the peak of the pandemic with a note claiming that the trust would “track any leaks to the media” and then “offer you the chance to post your P45 on Facebook for all to see.” The email, which described journalists at one respected newspaper as “parasites”, was sent to dozens of nurses and junior doctors. It has been examined by Liberty Investigates, the investigative journalism unit of the civil rights group Liberty, and the Guardian, after being shared by a recipient who said they found the language “intimidating”. Whistleblowers UK, the non-profit group, said it had been made aware of the email by a separate individual who was also concerned about its contents. The Royal Free London trust said the email was “badly worded” and did not reflect trust policy. However, the trust said it was an open and transparent organisation that “does everything it can to encourage our staff to raise concerns and, if necessary, whistleblow”. Read full story Source: The Guardian, 22 June 2020
  19. News Article
    Leading clinicians have written to Boris Johnson warning the UK faces a "second health catastrophe" because so many non-Covid patients are missing out on treatment as a result of the pandemic. The letter warns that “lives are being put at risk” and that action is needed immediately. It comes as new figures show as many as one in six (10 million) people will be on the NHS waiting list by the end of the year. The letter, signed by ten specialists, including cancer doctors, patient safety experts, CQCs and medical negligence lawyers, states: “We are increasingly concerned about the impact, including avoidable harm and death caused by the continuing unavailability of urgent diagnostics and treatment for thousands of non-COVID patients. “The backlog of such cases is now significant and worsening. We implore the central and devolved Governments of the UK to take urgent strategic action, including in co-ordination and co-operation with each other, to prevent this becoming a second and perhaps even more serious health catastrophe arising from the pandemic in the UK.” The letter was also signed by barrister Theo Huckle QC, Professor John Fairclough of Swansea and Cardiff Met Universities, Nick Brown of Doughty Street Chambers and Helen Hughes, Chief Executive, Patient Safety Learning. Cases which have come to the attention of the signatories include Sherwin Hall, 27, a father of one from Leeds, who made 13 visits to hospital during the COVID-19 lockdown before getting a cancer diagnosis for the pain in his groin. He said of his case: “I am very angry at the way I have been treated due to COVID-19 and the delay on my cancer treatment and now I am fighting for my life. Read full story Source: Express, 21 June 2020
  20. News Article
    Incoming Health Education England chief executive Navina Evans said the momentum created by the death of George Floyd and the Black Lives Matter movement meant there was now increased “pressure on white leaders” to act on racism and discrimination in the service. Dr Evans praised a letter written by Birmingham and Solihull Mental Health Foundation Trust chief executive Roisin Fallon-Williams, in which she admitted to being “culpable” and “complicit” in failing to fully understand the inequality and discrimination faced by people with black, Asian or other minority ethnic backgrounds. “That was great to see, and as you can see from the reactions to her letter people were really, really pleased to have it acknowledged,” she said. However, Dr Evans added: “As well as that [acknowledgement] there needs to be action”. Read full story Source: HSJ, 22 June 2020
  21. News Article
    A new coronavirus test which could replace the existing a nose and throat swab is being piloted in Southampton. People will be able to simply spit into a pot at home before the sample is sent off to check whether they have COVID-19. If successful, the saliva test could become an alternative to the existing swab which some people find uncomfortable and can provoke coughing and spluttering. Read full story Source: The Independent, 22 June 2020
  22. Content Article
    The International Society of Pharmacovigilance share their first infographic for patients and carers on using medicines safely during the COVID-19 pandemic. They developed the tool because of the difficulties experienced with obtaining and using medicines safely during the COVID-19 pandemic.
  23. Content Article
    Staff burnout was concern number 3 from ECRI’s Top 10 Patient Safety Concerns for 2019. This paper discusses staff burnout and the impact this can have on patient safety.
  24. Content Article
    ECRI position paper looking at post-intensive care syndrome (PICS) after covid. PICS, a nonspecific syndrome that results from physical, mental, and emotional stresses associated with critical illness and treatment in intensive care units.
  25. Content Article
    The Lilypond is a new conceptual model to describe patient safety performance. It radically diverges from established patient safety models to develop the reality of complexity within the healthcare systems as well as incorporating Safety II principles. There are two viewpoints of the Lilypond that provide insight into patient safety performance. From above, we are able to observe the organisational outcomes. This supersedes the widely used Safety Triangle and provides a more accurate conceptual model for understanding what outcomes are generated within healthcare. From a cross-sectional view, we are able to gain insights into how these outcomes come to manifest. This includes recognition of the complexity of our workplace, the impact of micro-interactions, effective leadership behaviours as well as patterns of behaviour that all provide learning. This replaces the simple, linear approach of The Swiss Cheese Model when analysing outcome causation. By applying the principles of Safety II and replacing outdated models for understanding patient safety performance, a more accurate, beneficial and respectful understanding of safety outcomes is possible.
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