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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Long waiting times for autism and attention deficit hyperactivity disorder (ADHD) assessments can prevent people from getting the vital care and medication they need. Health and education support often relies on a formal diagnosis, without which there can be severe negative consequences. Estimates show that there might be as many as 1.2 million autistic people and 2.2 million people with ADHD in England, and providing them with the right support is no small task. Recent news reports have highlighted a huge rise in demand for autism and ADHD diagnoses amid increased awareness and understanding of neurodiversity. Exploring referrals and waits for autism and ADHD assessments is a key first step to understanding the scale of the issue, which can then be used to drive improvements and change. This blog from the Nuffield Trust looks at what the data is telling us.
  2. Content Article
    The recently published results of the British Social Attitudes survey and the NHS Staff Survey, and recent performance data provide an in-depth backdrop to the health and care landscape in 2024 - a year that's likely to see a general election called. Ruth Robertson is joined by a panel of experts from The King's Fund to discuss the state of health and care. Throughout the conversation, the panel reflects on the prospect of a general election and the impact this might have on health and care services, both in the run up and after. They also discuss the tendency to rely on short-termism in policy-making, and why a long-term strategy might help build a stronger health and care system that will last.
  3. Content Article
    When Adam Luck’s mother, Ann, was admitted to hospital with a suspected stroke, it was the beginning of a distressing seven-week stay. The previously cheerful 82-year-old became stuck in a dysfunctional health system. Her story is presented here via her son Adam’s diary of her hospitalisation.
  4. News Article
    The new NHS gender identity clinics for young people are “understaffed” and “nowhere near ready”, it was claimed on Monday as they officially started taking on patients. A London hub, alongside a second in the northwest, will begin to see patients this week as they replace the Gender Identity Development Service (Gids) at the Tavistock and Portman NHS Foundation Trust. The Gids clinic was ordered to close after a review by Dr Hilary Cass found it was “not a safe or viable long-term option”. However, whistleblowers described as senior staff at Gids have expressed concerns about the preparedness and expertise of the new hubs, just as they open. One, who spoke to the i newspaper under the condition of anonymity, said: “It’s been shoddy, disorganised, messy and unclear. And at times, it’s felt unsafe.” Read full story (paywalled) Source: The Times, 1 April 2024
  5. News Article
    Drugs are a cornerstone of medicine, but sometimes doctors make mistakes when prescribing them and patients don’t take them properly. A new AI tool developed at Oxford University aims to tackle both those problems. DrugGPT offers a safety net for clinicians when they prescribe medicines and gives them information that may help their patients better understand why and how to take them. Doctors and other healthcare professionals who prescribe medicines will be able to get an instant second opinion by entering a patient’s conditions into the chatbot. Prototype versions respond with a list of recommended drugs and flag up possible adverse effects and drug-drug interactions. “One of the great things is that it then explains why,” said Prof David Clifton, whose team at Oxford’s AI for Healthcare lab led the project. “It will show you the guidance – the research, flowcharts and references – and why it recommends this particular drug.” Read full story Source: The Guardian, 31 March 2024
  6. News Article
    Trusts could be exposed to increased negligence claims as a result of new NHS England guidance for a rare spinal condition, a royal college has claimed. The Royal College of Emergency Medicine (RCEM) has said updated national guidance on treating cauda equina syndrome could also lead to greater “inequity of access” due to issues accessing timely MRI scans at many accident and emergency departments. An NHS Resolution report in 2022 found delayed MRI scans were a significant factor in high-value clinical negligence claims, particularly those relating to management of spinal conditions. The guidance issued by NHSE’s Getting It Right First Time programme national pathway guidance says emergency MRIs for suspected CES should be taken within four hours of requests to radiology, and where this is not possible, “standard operating procedures” involving local spinal and radiology services should be in place for urgent out-of-hours scanning. Local provision for this “must be in place by June 2024,” the guidance says. NHSE said the GIRFT guidance has been endorsed by 11 clinical and patient bodies, including the Royal College of Radiologists and the Spinal Injuries Association. But RCEM, understood to be the only clinical body not to endorse the guidance, has issued a position statement last month stating that “few EDs, outside of tertiary centres, have access to 24/7 MRI scanning”. Read full story (paywalled) Source: HSJ, 3 April 2024
  7. News Article
    Catherine O’Connor was 17 when she died, having lost 14 litres of blood during high-risk surgery on her back. At her inquest, the surgeon who operated on her, John Bradley Williamson, told the coroner the procedure at Salford Royal Hospital in Greater Manchester had “progressed uneventfully” and “the blood loss was perhaps a little higher than one would usually anticipate but was certainly not extreme”. The coroner recorded a verdict of death by misadventure. Now Greater Manchester police are examining O’Connor’s death, in February 2007, and whether Williamson misled the coroner during the inquest in September that year. Catherine's family are now demanding a new inquest into her death in 2007. This is because in the days after O’Connor’s death, Williamson sent an internal letter to the head of the hospital’s haematology department, Simon Jowitt, describing the surgery as “difficult” and having involved “a catastrophic haemorrhage”. Williamson had also ignored advice to have a second surgeon present during the operation. Officers led by Detective Inspector Michael Sharples have commissioned two expert reports and sought advice from the Crown Prosecution Service ahead of a meeting with the coroner, who has been asked to consider reopening O’Connor’s inquest. Read full story (paywalled) Source: The Times, 31 March 2024
  8. Event
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    NHS Resolution’s Safety and Learning team in collaboration with the NW panel law firms, are hosting a virtual forum series on learning from claims to promote reflection and improve patient care. The purpose is to raise awareness of the support offered by NHS Resolution as your General Practice indemnifier along with the North West panel firms; Weightmans, Hempsons and Hill Dickinson. This will be of interest to both clinical and non-clinical staff involved in patient care across primary and urgent care . The format is interactive, with presentations followed by questions and panel discussion. Session 4: Pitfalls to prescribing better care Event programme: The invaluable role of pharmacists Common medicine error claims recommendations Q&A panel discussion Contributors: Joanne Hughes- Partner | Hill Dickinson Dr Anwar Khan - Senior Clinical Advisor for General Practice |NHS Resolution Register
  9. Event
    until
    NHS Resolution’s Safety and Learning team in collaboration with the NW panel law firms, are hosting a virtual forum series on learning from claims to promote reflection and improve patient care. The purpose is to raise awareness of the support offered by NHS Resolution as your General Practice indemnifier along with the North West panel firms; Weightmans, Hempsons and Hill Dickinson. This will be of interest to both clinical and non-clinical staff involved in patient care across primary and urgent care . The format is interactive, with presentations followed by questions and panel discussion. Session 3: Dissecting a claim part 2 Event programme: Exploration through the use of an illustrative case studyQ&A panel discussion Contributors: Chris Dexter - Partner | Weightmans Alison Brennan - Principal associate |Weightmans Register
  10. Event
    NHS Resolution’s Safety and Learning team in collaboration with the NW panel law firms, are hosting a virtual forum series on learning from claims to promote reflection and improve patient care. The purpose is to raise awareness of the support offered by NHS Resolution as your General Practice indemnifier along with the North West panel firms; Weightmans, Hempsons and Hill Dickinson. This will be of interest to both clinical and non-clinical staff involved in patient care across primary and urgent care . The format is interactive, with presentations followed by questions and panel discussion. Session 2: Helping general practice manage and learn from claims part 1 Event programme: Exploration through the use of an illustrative case study Q&A panel discussion Contributors: Chris Dexter - Partner | Weightmans Alison Brennan- Principal associate |NHS Resolution Register
  11. Event
    until
    NHS Resolution’s Safety and Learning team in collaboration with the NW panel law firms, are hosting a virtual forum series on learning from claims to promote reflection and improve patient care. The purpose is to raise awareness of the support offered by NHS Resolution as your General Practice indemnifier along with the North West panel firms; Weightmans, Hempsons and Hill Dickinson. This will be of interest to both clinical and non-clinical staff involved in patient care across primary and urgent care . The format is interactive, with presentations followed by questions and panel discussion. Session 1: Seeking support for claims The session will explain how NHS Resolution, and its panel firms, will support you in responding to claims along with an overview of the legal tests used to determine a claim and the steps involved. Event programme: Introduction to the GP Indemnity scheme and clinical negligence Q&A panel discussion Contributors: • Patricia Roe - Partner | Hempsons • Dr Anwar Khan - Senior Clinical Advisor for General Practice, NHS Resolution Register
  12. Content Article
    On 27 February 2024, NHS Resolution's Safety and Learning team delivered a virtual forum on delivering health in the prison and justice system. The aim of the session was to discuss the realities, best practice, challenges and recommendations around collaborating to support healthcare delivery in the justice system.
  13. News Article
    Families have been told they will have to prove liability for the harm caused to mothers and children at East Kent Hospitals University Foundation Trust before getting compensation. This is despite the inquiry having examined each case in detail and concluding 45 babies could have survived, while 12 who sustained brain damage could have had a different outcome. It also determined 23 women who either died or suffered injuries might have had better outcomes had care been given to “nationally recognised” standards. However, NHS Resolution – which handles claims for clinical negligence – now says families must prove causation and a breach of duty of care before any compensation can be made. This stipulation has been made even in cases where the inquiry found different treatment would have been reasonably expected to make a difference to the outcome. The investigation into the trust’s maternity care led by Bill Kirkup reported 18 months ago. Speaking to HSJ, its author said: “I am disappointed that East Kent families are facing these problems after everything that has happened to them. Of course, it is true that the independent investigation panel was not in a position to rule on negligence, but we did provide a robust clinical assessment of each case. “I would have hoped that this could be taken into account in deciding to offer early settlement instead of a protracted dispute. It seems sad that a more compassionate approach has not been adopted.” Read full story (paywalled) Source: HSJ, 2 April 2024
  14. News Article
    Kara Dilliway was just three years old when she came down with a common ear infection in October 2022. She recovered quickly, as was expected, but just days after the infection cleared her parents found she was struggling to hear and talk. “We’d noticed she’d just started to say yes and no to things, that’s when we thought something is going on,” says her mother Sam Dilliway, a 41-year-old community care worker from Basildon, Essex. Doctors said she could have glue ear, a common condition in children – fluid build-up had started to cause problems with her hearing, and would need draining. But what should have been a minor ailment has turned into a never-ending ordeal for the family. What was a simple case of glue ear could now leave her with hearing loss for up to two years as she awaits routine treatment. It comes after data released in January found that over 10 million people have been left on NHS waiting lists for basic ear care services. Dr Aymat says that the long-term effects of such conditions being left untreated in children can be severe. While glue ear is unlikely to leave permanent damage, there is always a small risk of permanent hearing loss. However, the developmental effects are far more likely and potentially long-lasting. Read full story Source: The Independent, 1 April 2024
  15. Content Article
    Prime Minister Rishi Sunak promised speedier care, but specialists believe long waits for hospital beds are costing thousands of lives. The pledge he made in January last year, as one of five priorities on which he said voters should judge him, was that “NHS waiting lists will fall and people will get the care they need more quickly”. New calculations by the Royal College of Emergency Medicine (RCEM) show that, with regard to the broader aim of delivering speedier treatment, his government is falling shockingly short.
  16. News Article
    Hospitals are preparing to cut spending on doctors and nurses by hundreds of millions of pounds after being ordered to plug a £4.5 billion hole in the NHS budget. Chief executives at hospitals, mental health trusts and community services in England have been ordered to review staffing levels and draw up plans to close some services and merge others. They are also looking at banning or restricting the use of some agency workers. NHS bosses have been alerted in recent days to the scale of the cuts needed after negotiating financial plans for next year. The health service in England has a budget of £165 billion for the 2024-25 financial year, which starts next week. The budget rose by 3.2% in real terms between 2018-19 and 2023-24. Spending has been put under additional pressure by the cost of covering strikes by junior doctors which NHS England has said has cost more than £1.5 billion and affected more than 430,000 patients’ appointments. Saffron Cordery, deputy chief executive of NHS Providers, said services had been stretched by the need to pick up the pieces from a shortage of social care and other community services. She said an ageing population and poor public health meant patients in hospital were sicker and staying longer, needing more care. She said: “Trust leaders are being pushed to the very limits of what is possible, and there will be a situation where they have to make difficult choices about keeping basic services going versus investing in quality and improvement for the future. We are in a situation where we will be patching something that’s already a bit patched-together.” Read full story (paywalled) Source: Times, 31 March 2024
  17. Content Article
    Lit Health will be lighting a fire underneath the status quo of healthcare through interviews with authors, healthcare leaders, and policymakers working to create a healthcare environment that is equitable, transparent, and that welcomes the needs of every patient – especially our vulnerable populations including the mentally ill, people of colour and women who feel they are at risk in our current system, the elderly, and anyone who feels bias or the isms affect their health and quality of life.
  18. Content Article
    Health Services Research (HSR) conceptual models examine the complexity and “basic science” of patient safety. HSR methods can help quantify patient safety problems, enhance their understanding, and develop and test solutions. However, preventable harm persists and even worsened during the pandemic. One reason is inadequate attention and investment in patient safety over the past two decades. Significant investments are still needed to measure the burden of different patient safety events across settings and to address emerging safety threats. Solutions need to be developed, evaluated, and implemented through rigorous research to ensure widespread, effective adoption. Multidisciplinary strategies are required both to mitigate safety threats before they lead to patient harm, and to close the implementation gap. Outside of AHRQ and VA funding, patient safety research in the United States is underfunded. Efforts to translate HSR to patient care, policy, and clinical practice is essential for patient safety improvements. These efforts require health services researchers to go beyond publishing a paper; they must work closely with healthcare organizational leaders, clinicians, policymakers, and patients to ensure their findings are acted upon, and to help propose and test solutions. The National Center for Patient Safety (NCPS) offers an excellent model to do so by funding dedicated patient safety centres of inquiry (PSCIs) nationally. PSCIs focus on research and implementation activities that promote organization-wide learning. The PSCI model adds significant value to creating a learning health system for safety that invests in patient safety data gathering, analysis, learning, and actionable improvements.
  19. Content Article
    In March 2018, Elliot Peters, 14, died after becoming suddenly and seriously ill before being diagnosed with Ornithine transcarbamylase (OTC) deficiency. His mum, Holly, is dedicated to speaking out about Elliot’s story to raise awareness and prevent more deaths.
  20. Content Article
    As Rob Behren steps down as the Parliamentary and Health Service Ombudsman (PHSO) he records an episode of Radio Ombudsman, reflecting on his seven years in office. He also tells us about his early life, his career before PHSO and shares his future plans.
  21. News Article
    Experts and patient groups have warned that the high cost of private Covid vaccinations could exacerbate health inequalities and leave those more at risk from the virus without a vital line of defence. Both high street chain Boots and pharmacies that partner with the company Pharmadoctor are now offering Covid jabs to those not eligible for a free vaccination through the NHS, with the former charging almost £100 for the Pfizer/BioNTech jab. While Pharmadoctor says each pharmacy sets its own prices, it suggests the Pfizer/BioNTech jab will set customers back £75-£85, while the latest Novavax jab will cost about £45-£55. However experts have raised concerns that the high cost of the private jabs will widen inequalities, with the vaccinations unaffordable for many. “The most disadvantaged in society are most likely to be exposed to respiratory viruses due to things like poverty, intergenerational households and crowded workplaces. While they might be most in need of a seasonal vaccine, they will also be the least likely to afford £100 in the midst of a cost of living crisis,” said Dr Marija Pantelic, of the University of Sussex. Read full story Source: The Guardian, 28 March 2024
  22. News Article
    Patients are dying needlessly every year due to vulnerable Britons with heart problems not being given antibiotics when they visit the dentist, doctors have said. Almost 400,000 people in the UK are at high risk of developing life-threatening infective endocarditis any time they have dental treatment, the medics say. The condition kills 30% of sufferers within a year. A refusal to approve antibiotic prophylaxis (AP) in such cases means that up to 261 people a year are getting the disease and up to 78 dying from it, they add. That policy may have caused up to 2,010 deaths over the last 16 years, it is claimed. That danger has arisen because the National Institute for Health and Care Excellence (NICE) does not follow international good medical practice and tell dentists to give at-risk patients antibiotics before they have a tooth extracted, root canal treatment or even have scale removed, the experts claim. The doctors – who include a professor of dentistry, two leading cardiologists and a professor of infectious diseases – have outlined their concerns in The Lancet medical journal. In it, they urge NICE to rethink its approach in order to save lives, citing pivotal evidence that has emerged since the regulator last examined the issue in 2015, which shows that antibiotics are “safe, cost-effective and efficacious”. Read full story Source: The Guardian, 2 April 2024
  23. Content Article
    The British Social Attitudes (BSA) survey assesses public mood about the NHS, and the 2023 results reveal record low levels of satisfaction with the health service. This Nuffield Trust blog takes a closer look at what the results tell us.
  24. News Article
    All trusts should pick a “designated lead” for improving how they work with primary care, according to new NHS planning guidance. The guidance for 2024-25 published by NHS England today states: “Every trust should have a designated lead for the primary–secondary care interface.” It also asks integrated care boards to “regularly review progress” on how secondary care services are working with primary care. NHSE recovery plans include trying to cut the number of patients effectively referred back to GP practices by other services, in order to reduce GP workload. The guidance states: “Streamlining the patient pathway by improving the interface between primary and secondary care is an important part of recovery and efficiency across healthcare systems”. The planning guidance — published on Wednesday night after months of delays — also said systems should continue to develop integrated neighbourhood teams, including by trying to “improve the alignment of relevant community services” to primary care network footprints. Read full story (paywalled) Source: HSJ, 27 March 2024
  25. Content Article
    The NHS England 2024/25 priorities and operational planning guidance reconfirms the ongoing need to recover core services and improve productivity, making progress in delivering the key NHS Long Term Plan ambitions and continuing to transform the NHS for the future.
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