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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    When ECRI unveiled its list of the leading threats to patient safety for 2024, some items are likely to be expected, such as physician burnout, delays in care due to drug shortages or falls in the hospital. However, ECRI, a non-profit group focused on patient safety, placed one item atop all others: the challenges in helping new clinicians move from training to caring for patients. In an interview with Chief Healthcare Executive®, Dr. Marcus Schabacker, president and CEO of ECRI, explained that workforce shortages are making it more difficult for newer doctors and nurses to make the transition and grow comfortably. “We think that that is a challenging situation, even the best of times,” Schabacker says. “But in this time, these clinicians who are coming to practice now had a very difficult time during the pandemic, which was only a couple years ago, to get the necessary hands-on training. And so we're concerned about that.”
  2. News Article
    NHS teams are giving up on patients with severe eating disorders, sending them for care reserved for the dying rather than trying to treat them, a watchdog has warned the government. In a letter to minister Maria Caulfield, the parliamentary health service ombudsman Rob Behrens has hit out at the government and the NHS for failures in care for adults with eating disorders despite warnings first made by his office in 2017. The letter, seen by The Independent, urged the minister to act after Mr Behrens heard evidence that eating disorder patients deemed “too difficult to treat” are being offered palliative care instead of treatment to help them recover. The ombudsman first warned the government that “avoidable harm” was occurring and patients were being repeatedly failed by NHS systems in 2017, following an investigation into the death of Averil Hart. The 19-year-old died while under the care of adult eating disorder services in Norfolk and Cambridge. In 2021, following an inquest into her death and the deaths of four other women, a senior coroner for Cambridge, Sean Horstead, also sent warnings to the government about adult community eating disorder services. Read full story Source: The Independent, 27 March 2024
  3. News Article
    An investigation published by The BMJ today reveals new details of requests to recall striking junior doctors from picket lines for patient safety reasons. Documents show that while most trusts in England did not make such requests, those that did were rejected by the BMA in most cases. Some of these trusts warned of potential harm to patients from cancelling operations at the last minute and short staffing, reports assistant news editor Gareth Iacobucci. However, the BMA said it takes concerns about patient safety “incredibly seriously” and provided The BMJ with summaries of why requests were turned down. The union’s chair of council Phil Banfield said, “Throughout industrial action we have engaged thoroughly and in good faith with the derogation process, considering each request carefully to ensure that granting a derogation is necessary and the last and only option.” He said that poor planning by some trusts had led to some routine care being inappropriately booked in on strike days. In other instances, he said trusts had failed to make sufficient effort to draft in the necessary cover for strike days. Read full story Source: BMJ, 28 March 2024
  4. News Article
    Patients at the hospital that treated killer Valdo Calocane were discharged too soon and released in a worse state into the community, the NHS safety watchdog has found. Serious failings by Nottinghamshire Hospital Foundation Trust in keeping patients and the public safe have been identified in a review from the Care Quality Commission (CQC). More than 1,200 patients are waiting to be seen by community services, the report found. Meanwhile, several hundred who are receiving treatment did not have a clinician overseeing their care,the CQC found. The review was launched by the government following the conviction of killer Valdo Calocane, who was under the care of the NHS trust’s community services. The CQC review said patients reported that crisis services are either “useless” or detrimental to their health. The three broad areas of concern, highlighted in the CQC’s report, were: High demand for services was leading to long waiting times for care and a lack of oversight of those waiting. The trust does not have enough staff to keep patients safe in the community and within some hospital services. Senior leaders at the trust do not have clear oversight of the risks and issues within the service. Read full story Source: The Independent, 27 March 2024
  5. Content Article
    Following the conviction of Valdo Calocane in January 2024 for the killings of Ian Coates, Grace O’Malley-Kumar and Barnaby Webber, the Secretary of State for Health and Social Care commissioned the Care Quality Commission (CQC) to carry out a rapid review of Nottinghamshire Healthcare NHS Foundation Trust (NHFT) under section 48 of the Health and Social Care Act 2008. As part of the review, CQC were asked to look at 3 specific areas: A rapid review of the available evidence related to the care of Valdo Calocane An assessment of patient safety and quality of care provided by NHFT An assessment of progress made at Rampton Hospital since the most recent CQC inspection activity In this report, CQC detail the findings of parts 2 and 3. They will publish a separate report on part 1 in relation to the care of VC in summer 2024.
  6. Content Article
    Improving maternity care is a key Government and National Institute for Health and Care Research (NIHR) priority. In March 2024, an NIHR Evidence webinar showcased research from their recent Collection, Maternity services: evidence to support improvement.  This summary includes videos of researchers’ presentations and captures some of the points raised in the webinar Q&A. It highlights seven features of safety in the maternity units, kind and compassionate care around the induction of labour, and the role of hospital boards in improving maternity care.
  7. Event
    Our Human Factors – Applying to Incident Investigation programme is designed to equip staff with the knowledge and skills to use a systems approach to incident investigation. This is a great opportunity for programme participants to develop their understanding of Human Factors and apply this methodology to case studies with peers. The programme introduces the concept of system thinking and provides participants with the opportunity to discuss their own work context. Participants will grow their investigative mindset, whilst developing their knowledge and skills of the investigative process from the event timeline to recommendations for improvement. The programme also includes the opportunity to discuss and reflect on the essential components of good investigation, including; Being open and honest. Duty of candour. Co-designing investigations. Just culture. Systems based frameworks. Closing the loop from recommendations to action. Human Factors – Applying to Incident Investigation will take place on 9, 16 and 23 May 2024. Who is this for? The programme is aimed at all staff who are required to carry out or oversee incident investigation. Programme duration This is a 3 day programme. Delivery methods This programme is delivered virtually.
  8. Event
    This introductory course from AQUA is aimed at those who are new to Human Factors or those who are interested in refreshing existing knowledge. You will gain the fundamental knowledge and skills for Human Factors in health and care. Taking place online over two half days, this course will blend guided independent study with facilitated discussion and activities. You will be encouraged to apply your learning to your own role and environment, to reduce error, improve processes that underpin patient safety, and support organisational safety culture. Learning objectives: Understand the basic concept of Human Factors Understand the importance of Human Factors for safety and quality improvement Have awareness of what influences human and system performance Understand the basic concepts of systems thinking Who is this for? This programme is ideal for any staff who wish to develop a basic knowledge/awareness of human factors. Programme duration This programme consists of two sessions which will each last for three hours. Delivery methods This programme is delivered virtually through online sessions. Register
  9. Event
    This introductory course from AQUA is aimed at those who are new to Human Factors or those who are interested in refreshing existing knowledge. You will gain the fundamental knowledge and skills for Human Factors in health and care. Taking place online over two half days, this course will blend guided independent study with facilitated discussion and activities. You will be encouraged to apply your learning to your own role and environment, to reduce error, improve processes that underpin patient safety, and support organisational safety culture. Learning objectives: Understand the basic concept of Human Factors Understand the importance of Human Factors for safety and quality improvement Have awareness of what influences human and system performance Understand the basic concepts of systems thinking Who is this for? This programme is ideal for any staff who wish to develop a basic knowledge/awareness of human factors. Programme duration This programme consists of two sessions which will each last for three hours. Delivery methods This programme is delivered virtually through online sessions. Register
  10. Content Article
    Harm due to medicines and therapeutic options accounts for nearly 50% of preventable harm in medical care. This World Health Organization (WHO) policy brief is a resource for policy-makers, health workers, healthcare leaders, academic institutions and other relevant institutions to help understand the global burden of medication errors, address and prevent medication-related harm at all levels of healthcare, aligned with the strategic plan of the third WHO Global Patient Safety Challenge: Medication Without Harm. 
  11. News Article
    A new mum was confused for another patient and mistakenly fitted with a contraceptive coil after a C-section. Another patient in north Wales almost had the wrong toe removed during surgery to amputate two others. A third incident happened when a patient, unable to swallow oral medication, had it crushed, mixed with water and administered with a syringe. These so-called "never events" happened at hospitals in the Betsi Cadwaladr health board area in February. In a report into the three incidents in February, Betsi Cadwaladr health board outlined how a patient had a coil - an intrauterine device which prevents pregnancy - inserted after undergoing a Caesarean section. Described in the report as "wrong procedure", it had been planned for a different patient but a mistake had been made after the "list order was changed due to the increase in category for this patient". Another incident, described in the report as "wrong site surgery", described a patient who was due to have their second and third toes amputated. However, an incision was made in their fourth toe by accident. Luckily, the error was spotted and the correct toes were amputated. In the third never event, described as "wrong route", the report details the case of a patient who was unable to swallow oral medication. To administer it, a member of staff crushed it, mixed it with water and "inadvertently" gave it intravenously, according to the report. Read full story Source: BBC News, 28 March 2024
  12. Content Article
    Patients in England value the NHS App, but some users say there are limits to the information they can access, or find it difficult to use, according to a new report from the Digital Coalition.  Patients who need help to use the NHS App would value more support materials to enable them to use it independently, according to the report’s findings. But survey respondents were clear that using the NHS App must remain the patient’s choice, and face-to-face services must be retained. The report is based on findings from a survey run by The Patient Coalition for AI, Data and Digital Tech in Health (also known as the Digital Coalition). More than 600 people from across England completed the survey.
  13. News Article
    A senior mental health nurse suffered “degrading and humiliating” treatment while she languished for 10 days on an unsuitable NHS ward during a mental health crisis, The Independent has been told. Rachel Luby, 36, was admitted to Basildon Hospital A&E in Essex on 5 January this year after attempting to take an overdose of over-the-counter medicine following a traumatic assault. This, she claimed, was the start of weeks of horrific care she endured while waiting for a mental health bed. It culminated in her being restrained and forced into a caged van “like an animal”. She revealed her story after The Independent reported on a warning from top emergency doctors that self-harming and suicidal patients who go to A&E are not being treated with compassion because staff are overwhelmed. Ms Luby, an award-winning nurse, said she waited more than a week and a half in a general hospital before she was moved to a bed on a mental health ward. Ms Luby was able to leave the ward and find medication to overdose again, despite staff allegedly assessing her as a risk. In a second incident, she went to the bathroom and attempted to take her own life. She told The Independent: “I feel that this is something I will not recover from. I will not ever reach out for help in the future. “If this is the treatment that I’m getting as a nurse, then what the heck is happening to those that don’t have the voice or education that I have? It horrifies me to think what is happening to people that are far more vulnerable than me.” Read full story Source: The Independent, 27 March 2024
  14. News Article
    Trusts will be told to hit the four-hour A&E target in 78% of cases by next year after NHS England finally made an agreement with government, HSJ understands. The new target is just two percentage points higher than the target set for the current year of 76% – and must be hit in March 2025, according to NHS planning guidance. NHS England will also aim to maintain “core” general and acute beds at 99,000 on average across 2024-25 after funding was agreed with the government. This would maintain the beds at levels seen over recent months, but it would be a significant increase in the permanent “sustainable” beds available in the health service compared with previous years. Most trusts have fallen well short of the 76% target through much of 2023-24, and NHSE has pressed for them to make last-ditch attempts in recent weeks to try and get closer to the target ahead of the March 2024 deadline. This has included offering new capital funding rewards for improvement and telling trusts to focus on non-admitted patients. Elective recovery targets are expected to slip, and government has conceded making significant progress on these is almost impossible, with ongoing doctors strikes on top of other capacity problems. Read full story (paywalled) Source: HSJ, 27 March 2024
  15. Content Article
    This article analyses the phenomenon of epistemic injustice within contemporary healthcare. It begins by detailing the persistent complaints patients make about their testimonial frustration and hermeneutical marginalisation, and the negative impact this has on their care. The authors offer an epistemic analysis of this problem using Miranda Fricker's account of epistemic injustice. They detail two types of epistemic injustice, testimonial and hermeneutical, and identify the negative stereotypes and structural features of modern healthcare practices that generate them. They claim that these stereotypes and structural features render ill persons especially vulnerable to these two types of epistemic injustice. The authors end by proposing five avenues for further work on epistemic injustice in healthcare. "Without the narrative acts of telling and being heard, the patient cannot convey to anyone else – or to self – what he or she is going through. More radically and perhaps equally true, without these narrative acts, the patient cannot himself or herself grasp what the events of illness mean."
  16. Event
    WHO Infection Prevention and Control Global Webinar Series Each year the WHO’s World Hand Hygiene day aims to maintain a global profile on the importance of hand hygiene in health care and to ‘bring people together’ in support of hand hygiene improvement globally. On this day, everyone, in countries and health facilities, can renew their support and promote and implement strategies and innovations to improve hand hygiene practices in health care. Objectives: To promote a shared understanding of the fact that IPC education and training should be in place for all health workers by utilizing team- and task-based strategies that are participatory and include bedside and simulation training to reduce the risk of HAI and AMR. To outline the importance of campaigning for hand hygiene and WHHD 2024 resources. To outline and describe proposed WHHD 2024 activities. To stimulate engagement with the campaign on and around 5 May 2024. Register
  17. Content Article
    Evidence-informed decision-making (EIDM) entails identifying, appraising, and mobilising the best available evidence for safe and effective health policy and programmes. EIDM is a mainstay of the World Health Organization’s science-based mandate, and a pivotal steppingstone towards achieving the Triple WHO’s triple billion targets and the 2030 Agenda for Sustainable Development. This guide and associated tool repository provide WHO staff, Member States and partner organisations with vetted methods and tools to better leverage diverse forms of evidence for more effective policy and practice in the clinical, public health and health system fields. Introducing a comprehensive, multidisciplinary framework to plan and implement evidence-to-policy processes, the guide also aims to foster better collaboration and create synergies among actors and workstreams of the evidence ecosystem.
  18. Content Article
    In December 2024, the General Medical Council (GMC) will start regulating physician associates (PAs) and anaesthesia associates (AAs). The GMC have developed proposed rules, standards and guidance setting out how they will regulate these professions. They have also developed draft principles that will inform the content of decision-making guidance that will apply to doctors as well as to PAs and AAs from December 2024. This consultation is about those rules, standards and guidance and those principles. It is not about who should regulate PAs and AAs. This consultation asks for your comments on the General Medical Council's proposed rules, standards and guidance that set out how they will regulate anaesthesia associates (AAs) and physician associates (PAs). The consultation is open from 26 March to 11.59pm on 20 May 2024. 
  19. Event
    Join Emergency Services Times to delve deep into fostering a culture of that encourages speaking up in emergency services, shedding light on effective strategies and leaving outdated approaches behind. Reports into culture may grab headlines but underneath, it is about behaviour and creating a working environment and channels that allow staff to have a voice, speak up and report without fear of reprisal. Through the lens of Crimestoppers and the National Guardian's Office, we look at what works and how to move on from approaches that simply don't serve the needs of those working within the emergency services sector. Register
  20. Content Article
    In this episode, we hear from Sue Allison who blew the whistle on a Senior Radiologist within her department who repeatedly failed to diagnose women who had breast cancer at NHS Morecambe Bay Trust. She explains her battle to overturn her NDA at employment tribunal and the ‘insidious bullying’ that followed after blowing the whistle on concerns about patient safety. She is joined by Samantha Prosser an experienced employment law litigator from BDBF LLP who has specialist experience in advising private and NHS consultants from leading hospitals on private and NHS whistleblowing and discrimination claims.
  21. News Article
    A hacker group is in possession of at least a “small number” of patients’ data following a cyber-attack, NHS Dumfries and Galloway has said. Reports emerged on Wednesday of a post by the group Inc Ransom on its darknet blog, alleging it was in possession of three terabytes of data from NHS Scotland. The post included a “proof pack” of some of the data, which has been confirmed by the board to be genuine. The chief executive of the NHS board, Jeff Ace, said in a statement: “We absolutely deplore the release of confidential patient data as part of this criminal act. “This information has been released by hackers to evidence that this is in their possession. We are continuing to work with Police Scotland, the National Cyber Security Centre, the Scottish government and other agencies in response to this developing situation.” Patients whose data has been leaked will be contacted by the board, he said, while patient-facing services would continue as normal. Read full story Source: The Guardian, 27 March 2024
  22. News Article
    Measles cases in the US are rising, as major health organizations plead for increased vaccination rates and experts fear the virus will multiply among unvaccinated populations. Most notably, this year’s tally of measles cases has now outpaced last year’s total. On Thursday, there were 64 confirmed cases in 17 states, compared with 58 cases in the entirety of last year, according to the US Centers for Disease Control and Prevention (CDC). By Friday, the tally in Chicago grew by two to a total of 17. “Measles is one of the most contagious diseases known to man,” said Dr David Nguyen, an infectious disease specialist at Rush University Medical Center. Experts say that these incidents could approach the outbreak that spanned 31 states in 2019, when 1,274 patients got sick and 128 were hospitalized in the worst US measles outbreak in decades. “Every measles outbreak can be entirely preventable,” said Dr Aniruddha Hazra, associate professor of medicine at the University of Chicago. The American Medical Association has issued an appeal to increase vaccination rates, while the CDC released a health advisory urging providers to ensure all travelers, especially children over six months, receive the MMR vaccine. Read full story Source: The Guardian, 26 March 2024
  23. News Article
    Poor mental health cost society £300 billion in 2022 – the equivalent of double the NHS budget, according to new research. The figure covers economic costs such as sickness absence, human costs including reduced quality of life and wellbeing, and health costs such as care, the Centre for Mental Health said. The NHS Confederation’s mental health network, which commissioned the centre to carry out the research for the year 2022, said it shows that a failure to invest in early mental health help is a “false economy” which is making the country poorer and “causing unspoken anguish” to those affected. The report’s authors said the majority of costs stemming from mental ill-health fall on sufferers and their families – amounting to some £175 billion. The researchers said their study incorporates for the first time some of the wider costs, including the impact of presenteeism – whereby someone experiencing mental health difficulties attends work but is less productive due to impaired cognitive function and emotional distress. The report stated: “While it is impossible to fully assess the extent of the problem, and a pound sign is admittedly an imperfect proxy for some of the impacts, there is nevertheless value in estimating the economic cost of mental ill-health. “It helps us to appreciate the significance of mental ill-health as an issue deserving of policy attention, investment and reform.” Read full story Source: The Independent, 27 March 2024
  24. News Article
    Senior bosses have shared concerns about the closure of the NHS gender identity clinic for young people, leaked emails seen by BBC News reveal. Hospital executives voiced worry about the cancellation of appointments, patients lacking information and poor communication with the new services. In one email, the service's director, Dr Polly Carmichael, said cancellations could potentially put patients at risk. The controversial Gender Identity Development Service (Gids), which is run by the Tavistock and Portman NHS Foundation Trust, is due to close later this week. Its closure was announced in July 2022, after an independent review said a "fundamentally different" model of care for young people with gender-related distress was needed. It will initially be replaced by two new regional hubs; a London-based southern hub and a north of England hub. Additional hubs are expected to open in the coming years. However, BBC News has spoken to staff at the existing service who say, just days before the 31 March closure, they have been unable to answer basic questions from patients about the future of their care. They say they still do not have enough details about how the new services will operate or when some provisions will be fully operational in the new clinics. Read full story Source: BBC News, 27 March 2024
  25. News Article
    Public satisfaction with the NHS has dropped again, setting a new low recorded by the long-running British Social Attitudes survey. Just 24% said they were satisfied with the NHS in 2023, with waiting times and staff shortages the biggest concerns. That is five percentage points down on last year and a drop from the 2010 high of 70% satisfaction. The findings on the NHS, published by the Nuffield Trust and King's Fund think tanks, show once again that performance has deteriorated after a new record low was seen last year. In total, since 2020, satisfaction has fallen by 29 percentage points. Of the core services, the public was least satisfied with A&E and dentistry. The survey also showed satisfaction with social care had fallen to 13% - again the lowest since the survey began. The major reasons for dissatisfaction were long waiting times, staffing shortages and lack of funding. Read full story Source: BBC News, 27 March 2024
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