Jump to content
 View Profile  See their activity

  • Posts

    11,589

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

Everything posted by Patient Safety Learning

  1. 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
  2. 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
  3. 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.
  4. 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
  5. 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.
  6. News Article
    Tens of thousands of people with type 1 diabetes in England are to be offered a new technology, dubbed an artificial pancreas, to help manage the condition. The system uses a glucose sensor under the skin to automatically calculate how much insulin is delivered via a pump. Later this month, the NHS will start contacting adults and children who could benefit from the system. But NHS bosses warned it could take five years before everyone eligible had the opportunity to have one. This is because of challenges sourcing enough of the devices, plus the need to train more staff in how to use them. In trials, the technology - known as a hybrid closed loop system - improved quality of life and reduced the risk of long-term health complications. And at the end of last year, the National Institute of Health and Care Excellence (Nice) said the NHS should start using it. Prof Partha Kar, NHS national speciality advisor for diabetes, said the move was "great news for everyone with type 1 diabetes". "This futuristic technology not only improves medical care but also enhances the quality of life for those affected," he added. Read full story Source: BBC News, 2 April 2024 Related reading on the hub: How safe are closed loop artificial pancreas systems?
  7. News Article
    More than 250 patients a week could be dying unnecessarily, due to long waits in A&E in England, according to analysis of NHS data. The Royal College of Emergency Medicine analysed the 1.5 million who waited 12 hours or more to be admitted in 2023. A previous data study had calculated the level of risk of people dying after long waits to start treatment and found it got worse after five hours. The government says the number seen within a four-hour target is improving. This is despite February seeing the highest number of attendances to A&E on record, it adds. The Royal College of Emergency Medicine (RCEM) carried out a similar analysis in 2022, which at that time resulted in an estimate of 300-500 excess deaths - more deaths than would be expected - each week. The analysis uses a statistical model based on a large study of more than five million NHS patients that was published in 2021. RCEM president Dr Adrian Boyle said long waits were continuing to put patients at risk of serious harm. "In 2023, more than 1.5 million patients waited 12 hours or more in major emergency departments, with 65% of those awaiting admission," he said. "Lack of hospital capacity means that patients are staying in longer than necessary and continue to be cared for by emergency department staff, often in clinically inappropriate areas such as corridors or ambulances. "The direct correlation between delays and mortality rates is clear. Patients are being subjected to avoidable harm." Read full story Source: BBC News, 1 April 2024
  8. Content Article
    The idea of Emergency care services experiencing seasonal spikes in demand – so called ‘Winter Pressures’ are fast becoming a thing of the past. Instead, long waits have become the new norm year-round, and staff are caring for patients in unsafe conditions on a daily basis. It is well established that long waits are associated with patient harm and excess deaths. Last year the UK Government published a Delivery Plan for the Recovery of Urgent and Emergency Care (UEC) services. A year on, far too many patients are still coming to avoidable harm.   New analysis by the Royal College of Emergency Medicine (RCEM) reveals that there were almost 300 deaths a week associated with long A&E waits in 2023.
  9. Community Post
    @ClaraR_ose Thank you for sharing your experience. I am so sorry you went through such pain. At Patient Safety Learning we continue to call for more research and training in this area, and for all pain management options to be consistently offered to, and discussed with, women undergoing IUD procedures. Most importantly we are calling for women to be listened to and their experiences routinely captured by health services so the extent of these experiences can be fully understood. We have featured on the hub a couple of research projects around painful IUD procedures. Although both have now closed, I've copied the links below as both provide contact details from the leads on the research if you wanted to follow up with them and speak to them about their research and campaigns: Coil procedures: Exploring negative experiences through qualitative research (an interview with Sabrina Pilav) The pain of my IUD fitting was horrific…and I’m not alone
  10. Content Article
    Letter Patient Safety Commissioner, Henrietta Hughes, wrote to Amanda Pritchard, NHS England, on the implementation of Martha's Rule.
  11. Content Article
    More health systems and hospitals are looking to expand options to care for patients at home, but a new report points to some obstacles that threaten the safety of patients. ECRI, a nonprofit organisation focused on patient safety, released its annual list of the 10 leading healthcare technology hazards Wednesday. Safety challenges involving medical devices at home topped the 2024 list of technology trouble spots. ECRI also cites other challenges, including poor instruction in cleaning medical devices, sterile drug compounding, the insufficient governance of artificial intelligence in healthcare, and cybersecurity. But the concerns over the use of medical devices at home rose above all others. Marcus Schabacker, MD, president and CEO of ECRI, talked with Chief Healthcare Executive® about the potential hazards in patients using medical devices and tools at home.
  12. News Article
    The NHS is set to roll out artificial intelligence (AI) to reduce the number of missed appointments and free up staff time to help bring down the waiting list for elective care. The expansion to ten more NHS Trusts follows a successful pilot in Mid and South Essex NHS Foundation Trust, which has seen the number of did not attends (DNAs) slashed by almost a third in six months. Created by Deep Medical and co-designed by a frontline worker and NHS clinical fellow, the software predicts likely missed appointments through algorithms and anonymised data, breaking down the reasons why someone may not attend an appointment using a range of external insights including the weather, traffic, and jobs, and offers back-up bookings. The appointments are then arranged for the most convenient time for patients – for example, it will give evening and weekend slots to those less able to take time off during the day. The system also implements intelligent back-up bookings to ensure no clinical time is lost while maximising efficiency. It has been piloted for six months at Mid and South Essex NHS Foundation Trust, leading to a 30% fall in non-attendances. A total of 377 DNAs were prevented during the pilot period and an additional 1,910 patients were seen. It is estimated the trust, which supports a population of 1.2 million people, could save £27.5 million a year by continuing with the programme. The AI software is now being rolled out to ten more trusts across England in the coming months. Read full story Source: NHS England, 14 March 2024
  13. News Article
    While the importance of translating evidence into policies and practices is widely acknowledged by evidence producers, intermediaries, users, and funders, there is much less agreement on suitable mechanisms for promoting effective evidence use. As a response, the World Health Organization (WHO) has initiated an extensive and inclusive research priority-setting exercise in Knowledge Translation (KT) and Evidence-informed Policy-making (EIP) through a series of technical consultations. This priority-setting initiative, coordinated by the Evidence to Policy and Impact Unit in WHO’s Science Division, involves national and international researchers, practitioners, and organizations across all WHO regions. Collectively, they will assess the evidence base for effective research utilization in decision-making. The overarching goal of this project is to maximize the impact of KT and EIP research to promote the translation of evidence into effective policies that enhance population health and well-being. Key objectives include: Efficiency and Synergy: Streamlining research efforts in KT and EIP. Strategic Funding: Directing research funding toward identified priority areas. Effective Approaches: Enhancing understanding of evidence use for policy-making. Collaboration: Promoting cross-sectoral collaboration in KT and EIP research. Awareness: Championing for evidence-informed policy-making at all levels. In the first half of the 2024, global experts – selected during an open call – are now actively participating in a series of consultations to identify gaps and opportunities in KT and EIP research. The consultations provide a pivotal opportunity for participants to discuss current research gaps, harmonize terminology and chart a course toward shared priorities. Read full story Source: WHO, 22 March 2024
  14. 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.”
  15. 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
  16. 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
  17. 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
  18. 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.
  19. 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.
  20. 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.
  21. 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
  22. 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
  23. 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. 
  24. 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
  25. 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.
×
×
  • Create New...