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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Tens of thousands of doctors are hoping to quit the NHS and move abroad this year in search of better pay, the medical regulator has warned. Half of the doctors planning to leave said they wanted to move to Australia, which has been the most popular destination for emigrating UK doctors for the past five years. The General Medical Council surveyed 3,154 doctors about their attitudes towards leaving the UK, including 1,000 who had recently left to practise abroad. Some 13% of those working in the NHS said they were “very likely” to move in the next 12 months, while another 17% said they were “fairly likely” to move. The GMC said this would amount to 96,000 doctors quitting over the next year if applied to the total number of doctors on the medical register, although it acknowledged that the actual rate of departures was likely to be much lower. Read full story (paywalled) Source: The Times, 12 April 2024
  2. News Article
    The British government was willing to risk infecting NHS patients to get “lower-priced” blood products, according to a document that campaigners claim proves state and corporate guilt in one of the country’s worst ever scandals. A public inquiry into the deaths of an estimated 2,900 people infected with conditions such as HIV and hepatitis will publish its final report in May, four decades after the NHS started prescribing blood and blood products – including from drug users, prisoners and sex workers – sourced from the USA. Within the thousands of documents disclosed to the inquiry, internal company minutes have emerged that campaigners say provide the final compelling piece of evidence of the commercial greed and state negligence that destroyed thousands of lives. In November 1976, Immuno AG, an Austrian company that was a major supplier to the Department of Health, was seeking a licence change to allow it to supply a blood product from those paid to donate in the US rather than donors without a financial incentive in Europe. According to the minutes of a meeting of medics in the company, it had been “proven” that there was a “significantly higher hepatitis risk” from a concentrate known as Kryobulin 2 made from US plasma compared with that from Austria and Germany. The company had concluded there was a “preference” in the UK for the cheaper US option. The memo of the meeting said: “Kryobulin 2 will be significantly cheaper than Kryobulin 1 because the British market will accept a higher risk of hepatitis for a lower-priced product. In the long-term, Kryobulin 1 will disappear from the British market.” Read full story Source: The Guardian, 14 April 2024
  3. News Article
    Millions of patients are being put at risk in crumbling hospitals that are unfit for purpose, MPs have said, as figures reveal more than 2,000 NHS buildings are older than the health service itself. Health bosses have repeatedly warned ministers of the urgent need to plough cash into replacing rundown buildings in order to protect the safety of patients and staff. The maintenance backlog has risen to £11.6bn in England. Now analysis of NHS Digital data has found that at 34 out of 211 NHS trusts in England at least one in four buildings have been standing since before 1948, the year the NHS was founded. Sewage leaking from sinks on to wards are among the issues affecting more than 2,000 buildings that predate the health service. Last month it was reported that the ceiling of an intensive care ward collapsed on to a patient on life support and a falling lift broke a doctor’s leg. One hospital is said to have been using its intensive care unit as a storeroom because it deemed it unsafe for patients. Read full story Source: The Guardian, 15 April 2024
  4. Event
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    Digital transformation is vital, and this is the space to learn from leaders who are building efficient, personalized care. We’ll cut through the buzzwords and dive deep into the biggest issues in European healthcare—creating space for connection-building along the way. AI, workforce sustainability, preventative care, and digital transformation in action are the big topics we’ll cover. So are interoperability, health data, digitally-enabled care pathways, and patient empowerment. You’ll leave with insights you can take home and use to drive change. Programme Speakers Register
  5. Event
    This Grand Rounds session will cover three reports from the AHRQ Evidence-based Practice Center program focusing on making healthcare safer. Opioid stewardship interventions. Rapid response systems. Engaging family caregivers with structured communication for safe care transitions. Industry stakeholders will discuss the impact of these reports. Register
  6. Event
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    The TIPSQI Annual Quality Improvement Showcase returns once again in a virtual format. This virtual conference is open to all foundation doctors in the UK. This is a fantastic opportunity to present your QI project as a virtual poster or oral presentation; hear about other projects in the region; and hear our key note speaker Dr Hannah Baird, the founder of TIPS QI, alongside being higher specialty registrar in emergency medicine, Chief Registrar at Royal Bolton Hospital, the Vice-Chair of the Academy of Medical Trainees Doctors Group and the Co-Chair of the Emergency Medicine Trainees Association (RCEM). Junior doctors from around the UK will be presenting their quality improvement projects, highlighting some of the excellent leadership work being carried out amongst foundation doctors. There shall be prizes for the best projects, as well as the opportunity to learn more about the great QI work across the UK. Register
  7. Event
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    Energising excellence. Bringing research, education, practice and leadership to life The RCM conference is back for 2024. Professional and educational standards of proficiencies have made clear the importance of midwives working across the professional pillars of the profession: research, education, clinical practice and leadership. Safe and effective care needs an evidence base from research, which is then disseminated and supported through education and strategically implemented into clinical practice and sustained through effective leadership. Furthermore, understanding midwifery professional pillars is relevant for promoting career pathways and ensuring professional recognition alongside our multi-disciplinary colleagues. Register
  8. Event
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    Bevan Brittan are delighted to announce their next Digital Health and Care Forum. This session will be hosted in partnership with the Masala Network, the health and life science network for South Asians in the UK. At this in-person event, we will be joined by a panel of experts in the field including: Dr Amrita Kumar, AI Clinical Lead and Consultant Radiologist at NHS Haris Shuaib, Founder and CEO at Newton’s Tree Helen Hughes, Chief Executive at Patient Safety Learning Hassan Chaudhury, Co-Founder at Vita Health Care Solutions Daniel Morris, Partner at Bevan Brittan AI and data-driven technology continues to revolutionise health and care at a giddying pace and offers enormous opportunity to shape and future-proof health systems that could be more affordable, sustainable and equitable. But to fully realise AI’s transformational potential there is a pressing need to ensure public and clinical buy-in. In this session we will consider how evidence and ethical based frameworks and guidelines, patient safety measures and regulation can all foster trust in AI. The Digital Health & Care Forum is intended to be an interactive session and an opportunity and safe space to exchange views, identify and explore key issues and share knowledge. Our events are attended by developers, purchasers, providers, funders, insurers and policy makers. Register
  9. Content Article
    The Health & Social Care Committee is examining the relationship between leadership in the NHS and performance/productivity as well as patient safety. It will consider the findings of and implementation of recent reviews of NHS leadership, such as the Messenger (2022) and Kark (2019) reviews as they relate to patient safety, as well as topics including how effectively leadership supports whistleblowers and learning from patient safety issues. Here is AvMA's response to the Committee's call for evidence.
  10. News Article
    People attempting to contact their GP practice are almost three times as likely to report failing to get through in some integrated care systems (ICS) than others, according to NHS England-commissioned data. The survey figures, collected for the first time by the Office for National Statistics (ONS), show 8.5% of people nationally who tried to call their GP between mid-January and mid-February this year said they could not reach the practice. This equates to 1.5 million people across England, according to the ONS. In Northamptonshire – the worst performing ICS – 14.7% of callers did not manage to make contact. That is the equivalent of around one in seven people. By comparison, only 3.9% of callers in Gloucestershire, the best performing ICS, could not get through. The findings are broadly similar when population and age are accounted for. Read full story (paywalled) Source: HSJ, 12 April 2024
  11. News Article
    The continuing shortage of ADHD medication is causing those with the condition increasing stress and anxiety, the BBC has been told. Pharmacists said the problem persists despite a government assurance it would be resolved by the end of last year. In September, the Department for Health and Social Care (DHSC) blamed the UK-wide scarcity on "increased global demand and manufacturing issues". It said the disruption was "expected to resolve" between October and December. Lorraine Jukes, who has ADHD, said: "Here I am in April 2024, with only four days of medication left." The 36-year-old, from Iffley, Oxford, said she was "frantically phoning through lists of pharmacies" and being told there was no stock and no indication of any being available before she runs out. Oliver Picard, vice chair of the National Pharmacy Association, said: "We were told it would be resolved in December. "Some of the medication is starting to come back. In March, we had the supply of a certain brand of ADHD medication, we are now seeing shortages of other ADHD medication and we don't have a date for resupply. "Sometimes we can get some but will be limited to one packet per month pharmacy and that's not helpful either. It's hugely frustrating." Read full story Source: BBC News, 15 April 2024
  12. News Article
    A "gang culture" existed at an NHS neurosurgery department, a doctor has claimed at his employment tribunal. Neurosurgeon Mansoor Foroughi is one of two surgeons who alleges patients were put at risk at University Hospitals Sussex, where police are investigating 105 cases of alleged medical negligence. Four whistleblowers at the trust previously told BBC Newsnight that patients had died unnecessarily while others were "effectively maimed". They also complained of a "Mafia-like" management culture. Mansoor Foroughi alleges one colleague was approved to perform complex spinal surgery without adequate training. He claims a second surgeon undertook procedures that led to a "disproportionate" level of deaths. Mr Foroughi says a third surgeon undertook private work whilst on call to the NHS, which if true would be a breach of the NHS Code of Conduct. Universities Hospitals Sussex dismissed Mr Foroughi following a disciplinary hearing which upheld three allegations against him. He alleges the trust punished him because he raised these safety concerns. The trust said it would "vigorously contest" his claims. Read full story Source: BBC News, 11 April 2024
  13. News Article
    The boss of the NHS has made a dramatic intervention in The Independent highlighting the shocking amount of sexual abuse against staff in the health service, arguing that a #MeToo moment is needed to safeguard staff. Amanda Pritchard hit out at the “unacceptable” levels of abuse faced by doctors and nurses, demanding that health trusts be judged on their progress in tackling sexual harassment. She has called for sexual harassment against NHS staff to be “stamped out” after it emerged that one in eight workers – 58,000 – had reported experiencing unwanted sexual behaviour last year. Writing exclusively for The Independent, Ms Pritchard said the abuse now levelled at doctors and nurses is unacceptable – with some staff being raped at work, groped, and shown pornography. “The #MeToo movement has powerfully called out this unacceptable behaviour and fuelled important discussions right across society, and the NHS must not be exempt,” Ms Pritchard wrote. Around 58,000 NHS workers reported being subjected to unwanted sexual behaviour last year (PA) “But we can’t just call out unacceptable behaviour and move on: we need to stamp it out across all parts of the NHS.” Read full story Source: The Independent, 13 April 2024
  14. News Article
    A dedicated mental health and addiction support service for secondary care staff is shutting to new patients, as NHS England is set to cut its funding. The NHS Practitioner Health programme, which was rolled out nationally in October 2019, is halting new registrations for secondary care staff from 15 April. NHS England has informed the provider its funding will be cut for secondary care staff, subject to a review it is carrying out of wider services. The Practitioner Health programme for GPs and dentists is expected to continue for another year, although its future beyond that is also unclear, HSJ was told. An announcement published on X, formerly known as Twitter, said: “New secondary care patients will be signposted to alternative sources of support, including your GP, occupational health departments and organisational employee assistance programmes.” Its axing comes amid severe pressure on NHS budgets nationally and locally, with overall funding barely keeping up with anticipated inflation in 2024-25, and many integrated care systems forecasting large deficits. Medical unions and senior doctors have criticised the axing of the service. Read full story (paywalled) Source: HSJ, 12 April 2024
  15. News Article
    More than a dozen trusts have changed their maternity IT system – or are in the process of doing so – following a national patient safety alert. NHS England issued the alert in December, after a fault was discovered with the Euroking maternity EPR, supplied by Magentus Software. It said information recorded in the EPR could overwrite previously recorded data, meaning the system could mislead clinicians. While no cases of patient harm have been reported, NHSE instructed trusts using the system to “consider if Euroking meets their maternity service’s needs” and “ensure their local configuration is safe” by June. A spokesperson for Euroking said: “We have identified a solution to the issues raised in the NPSA [alert], which has been shared with NHSE and with our customers. We’re now meeting each customer and are working with them individually to support the changes that need to be made based on their local configurations. We will continue working with the trusts to support them meeting the deadline outlined in the NPSA. “As the NPSA outlined, it has been issued as a precautionary measure and there is no evidence of harm being caused to patients.” Read full story (paywalled) Source: HSJ, 12 April 2024 Related reading on the hub: NHS England warns electronic patient record could pose ‘serious risks to patient safety’: what can we learn?
  16. Content Article
    In February 2023, the Department of Health and Social Care (DHSC) published the government’s Medical Technology Strategy. This set out how, over the next 5 to 10 years, the DHSC will ensure the health and social care system can reliably access safe, effective and innovative technologies. These technologies will enable the delivery of high-quality care, outstanding patient safety and excellent health outcomes, while making the best use of taxpayer money.  One year into delivery of the medtech strategy, the DHSC present an update on their achievements towards establishing an innovation pathway, to realise our vision of right product, right price, right place. 
  17. Content Article
    Patients with Parkinson’s are at risk of significant harm if they don’t get their medication on time, every time. ‘On time’ means within 30 minutes of the patient’s prescribed time. Even short delays can worsen symptoms such as rigidity, pain and tremors, increasing the risk of falls. Over half of people with Parkinson’s don’t get their medications on time, every time in hospital. This leads to worse patient outcomes, longer recovery times and increased costs to the NHS.
  18. News Article
    There is huge regional variation in the rate at which health systems are preventing patients joining the elective waiting list through “advice and guidance” to GPs, according to analysis by HSJ. Some systems – including Northamptonshire – have managed to ramp up these “diverts” to such an extent that they now report around one A&G case to every 3.5 cases cleared from the waiting list through treatment or seeing a consultant. This contrasts with others, such as Lancashire and South Cumbria, which only reports one A&G case for every 16 cleared from the waiting list. Advice and guidance involves GPs consulting specialists before making direct referrals and around half the time this results in a referral being avoided. The model is set to be a cornerstone of NHS England’s new outpatient transformation strategy, which is due imminently. Victoria Tzortziou-Brown, vice chair of the Royal College of GPs, said the analysis “confirms reports we’ve heard from our members – that there is too much regional variation in the use of the ‘advice and guidance’”. She added: “Some GPs report that when advice and guidance is properly resourced and well implemented, it can be a helpful tool for improving communications with their colleagues in secondary care. “[But] it is clear that more time, funding and capacity needs to be dedicated to allow clinicians to communicate efficiently and effectively whilst respecting professionalism.” Read full story (paywalled) Source: HSJ, 9 April 2024 Related reading on the hub: Rejected outpatient referrals are putting patients at risk and increasing workload pressure on GPs
  19. News Article
    A man who suffered a psychotic episode which lasted for weeks was not fully informed about potential extreme side-effects of taking steroids medication, England’s health service Ombudsman has found. Andrew Holland was prescribed steroids in early January 2022 by Manchester Royal Eye Hospital after losing vision in his left eye and suffering a severe infection in his right eye. The 61-year-old from Manchester was given the medication as treatment for eye inflammation, but soon began suffering from disrupted sleep and severe headaches. These side-effects developed into more serious ones, including becoming aggressive, psychotic, and inexplicably wandering the street at different times of the day and night. After several hospital visits due to his symptoms, Andrew attended Manchester University NHS Foundation Trust’s emergency department in mid-January with a severe headache and later became an inpatient. He was diagnosed with steroid induced psychosis, with symptoms including hallucinations, insomnia and behaviour changes. Though no failings were found with Manchester University NHS Foundation Trust in prescribing Andrew with steroids for the eye condition, the Ombudsman discovered a missed opportunity to fully inform him of potential extreme side-effects. He was therefore unable to make a fully informed decision about whether to take them or not. The Trust apologised for an ‘unsatisfactory experience’. However, the Ombudsman found relevant guidelines were not followed. Moreover, there had been no acknowledgement of mistakes in communication about the side-effects. Nor was any attempt made to correct them. Read full story Source: PSHO, 10 April 2024
  20. Event
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    In the context of a multimodal improvement strategy, WHO highlights the importance of training of health workers for sustainable improvement in infection prevention and control (IPC), including hand hygiene. Many countries are demonstrating strong engagement and advancements in scaling-up infection prevention and control (IPC) strategies and actions, but overall, the progress is slow, and gains are at risk. In multiple WHO surveys for example, training and education was the weakest component of IPC programmes around the world both at the national and facility level. With a global workforce of 65 million health workers, this year's campaign focus on training and education and taking action on, for example, hand hygiene can help save lives. Objectives To describe the evidence for the value of IPC and hand hygiene education and training. To outline WHHD 2024 resources and activities. To introduce new products impacting IPC education and training. To promote a shared understanding that IPC education and training should be in place for all health workers to reduce the risk of HAI and AMR, including winners of the WHHD case study submissions. Register
  21. Event
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    This global webinar is organised to promote and mark the launch of "My 5 Moments: The Game," an innovative digital game developed through a collaboration between the WHO Infection Prevention and Control Unit and Hub, WHO Academy, game designer, learning game expert, and end users. Aimed at revolutionising hand hygiene education, this game-based learning programme integrates the concept of "My Five Moments for Hand Hygiene" into an engaging, compassionate, and scientifically-backed gaming experience. Set in the futuristic International Alien Hospital, the game challenges players to maintain optimal hand hygiene practices to ensure the safety of both alien patients and the Earth. This session aims to introduce healthcare professionals, educators, and other relevant stakeholders to the game's unique approach to infection prevention and control through gamification, design insights, and the importance of empathy in healthcare. Objectives: To introduce "My 5 Moments: The Game" to healthcare professionals, IPC practitioners, educators, and stakeholders, highlighting its innovative approach to hand hygiene education through gamification, and demonstrating how it can transform traditional learning methodologies in IPC. To provide insights into the game's design and development process, emphasizing the integration of compassion, care, and empathy into its gameplay, and illustrating the importance of these elements in creating a more effective and engaging learning experience for healthcare workers. To encourage the adoption of "My 5 Moments: The Game" within healthcare training and education programmes, to bring behavior change among healthcare workers, and offering guidance on integrating this innovative tool into existing IPC efforts. Register
  22. Content Article
    NHS England’s response to claims of excess deaths due to long A&E waits leaves a lot to be desired, writes Steve Black for the HSJ. The Royal College of Emergency Medicine (RCEM) claim that more than 250 A&E patients are dying each week because they waited more than 12 hours to be admitted. If long waits in A&E are killing an extra 250-400 people every week, it is the biggest performance problem in the NHS. NHSE should urgently ask their analysts to rework this analysis with current data to test (or refute) the validity of the claim. The first step to solving a huge problem is admitting the scale of the problem, not denying it exists. This analysis features a refinement of the RCEM estimate that includes estimated mortality from waits between four and 12 hours. This increases the estimate to 400 extra deaths per week compared to the RCEM number of 250.
  23. Content Article
    People with kidney failure or chronic kidney disease, whose kidneys have stopped working properly, may need dialysis. This therapy takes over the normal function of the kidneys and removes waste products and excess fluid from the blood. Many people have regular dialysis in hospital, where fluids are filtered by a machine (haemodialysis). In peritoneal dialysis, often carried out at home, a catheter is inserted in the abdomen and left there permanently. A catheter can be inserted under general anaesthetic by a surgeon, or without a general anaesthetic by a physician using a needle (medical insertion). Medical insertions have become more common in recent years due to a lack of access to surgeons and theatre space; they have the advantage of being possible in people who are not well enough to have a general anaesthetic. However, evidence on the safety and efficacy of medical insertions is lacking. This study assessed the number of safety events following catheter insertions for peritoneal dialysis via the medical and surgical route. Researchers explored the reasons for choosing medical, versus surgical catheter insertions.
  24. News Article
    Thousands of vulnerable children questioning their gender identity have been let down by the NHS providing unproven treatments and by the “toxicity” of the trans debate, a landmark report has found. The UK’s only NHS gender identity development service used puberty blockers and cross-sex hormones, which masculinise or feminise people’s appearances, despite “remarkably weak evidence” that they improve the wellbeing of young people and concern they may harm health, Dr Hilary Cass said. Cass, a leading consultant paediatrician, stressed that her findings were not intended to undermine the validity of trans identities or challenge people’s right to transition, but rather to improve the care of the fast-growing number of children and young people with gender-related distress. But she said this care was made even more difficult to provide by the polarised public debate, and the way in which opposing sides had “pointed to research to justify a position, regardless of the quality of the studies”. “There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.” Read full story Source: The Guardian, 10 April 2024
  25. Content Article
    Dr Hilary Cass has submitted her final report and recommendations to NHS England in her role as Chair of the Independent Review of gender identity services for children and young people. The Review was commissioned by NHS England to make recommendations on how to improve NHS gender identity services, and ensure that children and young people who are questioning their gender identity or experiencing gender dysphoria receive a high standard of care, that meets their needs, is safe, holistic and effective.  The report describes what is known about the young people who are seeking NHS support around their gender identity and sets out the recommended clinical approach to care and support they should expect, the interventions that should be available, and how services should be organised across the country. It also makes recommendations on the quality improvement and research infrastructure required to ensure that the evidence base underpinning care is strengthened.
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