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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. 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
  2. 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
  3. 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."
  4. 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
  5. 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.
  6. 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. 
  7. 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
  8. 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.
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. Content Article
    Public satisfaction with the NHS has fallen to the lowest level ever recorded, according to analysis of the latest British Social Attitudes survey (BSA) published by The King’s Fund and the Nuffield Trust. Just 24% of people are satisfied with the way the NHS is running, a fall of 5 percentage points from 2022 and a 29 percentage point drop since 2020. Despite these record lows, the overwhelming majority of survey respondents expressed high levels of support for the principles the NHS was founded upon, in particular that it should be free of charge when needed. Nearly half of those surveyed also support the government increasing taxes and spending more on the NHS.
  15. News Article
    An ambulance trust is having to protect its staff from the effects of fumes – including potential cancer risk – as they are spending so long in their vehicles outside hospitals. South Western Ambulance Service Foundation Trust (SWASFT) has carried out a risk assessment of the impact of diesel engine emissions after following concerns from staff, many of whom are spending hours waiting to handover on each shift. The region has faced the worst handover delays to emergency departments in recent years. Ambulance engines normally have to be kept on while waiting, to keep essential equipment running, and sometimes for warmth. But with queues of a dozen or more ambulances at times, staff and patients can be exposed to substantial emissions for long periods. The trust’s risk assessment – which has been seen by HSJ – warns exposure to diesel emissions is associated with eye and upper respiratory tract irritation, while prolonged exposure can lead to coughing, increased sputum production and breathlessness. There is also “epidemiological evidence which indicates that sustained occupational exposure to diesel engine exhaust emissions may result in an increase in the risk of lung cancer”. It gives a risk rating of 20 – one of the highest possible – which, under the trust’s policies, indicates “activities must not proceed” until mitigations are in place. Read full story (paywalled) Source: HSJ, 27 March 2024
  16. Content Article
    Research conducted by a team at the University of Birmingham delves into the intricate dynamics of empathy towards patients and colleagues, revealing insights that challenge conventional wisdom. Empathy is widely recognised as a cornerstone of medical care. Increased physician empathy has been linked to better patient outcomes and satisfaction, yet there has been little exploration of its presence in surgical training. The study involved interviews with 10 surgical trainees at various stages of their careers to uncover a nuanced understanding of empathy within the profession. Contrary to the widely documented decline in empathy among medical students and professionals, participants described their experiences as a balance between empathy and the demands of surgical practice. Participants acknowledged the importance of empathy in patient care but highlighted the challenges of maintaining it amid the pressures of a surgical environment. They described a delicate balance between understanding patients’ needs and the efficiency required to manage high patient volumes and demanding workloads. The study revealed how empathy evolves throughout a surgeon’s career. Whilst some trainees experienced desensitisation to emotional stimuli, many described increased empathy as they gained more experience and exposure to patient care.
  17. News Article
    The US Supreme Court will hear oral arguments on whether to restrict access to mifepristone, a commonly used abortion pill. It is considered the most significant reproductive rights case since the court ended the nationwide right to abortion in June 2022. The Biden administration hopes the court will overturn a decision to limit access to the drug over safety concerns raised by anti-abortion groups. The pill has been legal since 2000. The current legal battle in the top US court began in November 2022 when the Alliance for Hippocratic Medicine, an umbrella group of anti-abortion doctors and activists, filed a lawsuit against the Food and Drug Administration, or FDA. The group claims that mifepristone is unsafe and further alleges that the federal agency unlawfully approved its use in September 2000 to medically terminate pregnancies through seven weeks gestation. Mifepristone is used in combination with another drug - misoprostol - for medical abortions, and it is now the most common way to have an abortion in the US. Medical abortions accounted for 63% of all abortions in 2023, up from 53% in 2020, according to the Guttmacher Institute. In total, more than five million US women have used mifepristone to terminate their pregnancies. Read full story Source: BBC News, 26 March 2024
  18. News Article
    Government’s standards watchdog has launched a review into accountability in public bodies, warning that problems are too often not dealt with quickly and effectively. Over the next few months, the Committee on Standards in Public Life will look at “where public bodies should focus their attention to maximise the likelihood of problems being uncovered and addressed before issues escalate and lives are damaged”. In a letter to the prime minister about the review, CSPL chair Doug Chalmers said the committee had been “struck by how, when failures occur within public institutions, it repeatedly seems to be the case that indicators of emerging issues were present, but missed, with the result that the window to respond appropriately, before problems escalate, has often also been missed”. In its announcement of the review, CSPL said it had seen “several examples of major failures within public institutions” in recent years where “opportunities were missed to address issues before they escalated”. “We are asking, when things go wrong in public bodies, why does it take so long for problems to be recognised and the leadership to respond appropriately and, most importantly, what needs to change?” Rather than reinvestigating previous incidents, the committee will look at how to encourage more effective accountability within public bodies “so that problems are addressed before catastrophic failure”, Chalmers said. As part of the review, CSPL has opened a consultation today inviting members of the public to submit evidence on why public bodies might fail to act quickly when problems arise, along with suggestions on how to tackle problems better and examples of good practice. The consultation closes on 14 June. Read full story Source: Civil Service World, 25 March 2024
  19. Content Article
    Central to the Patient Safety Incident Response Framework (PSIRF) is the requirement for healthcare organisations to be proactive in how they respond to and learn from patient safety incidents. This article from legal firm Kennedys considers the implications of PSIRF on healthcare organisations’ legal and governance teams. In particular, considering practical steps that may be adopted, as an example, in the context of preparing for an inquest.
  20. Content Article
    Technology is advancing at a fast pace and holds significant promise for the future of healthcare and the NHS, with the potential to enhance productivity through cost, resource and time efficiencies. Yet there is a gap in practical guidance for healthcare stakeholders on how best to take this agenda forward, and what key roles are required. Systems are now in a place where people can take a large-scale view and make connections across the system to advance the technology agenda. To support them, the NHS Confederation and Google Health have developed this guide.
  21. Content Article
    Making hospitals more conducive to high quality sleep might benefit patient experience and wellbeing, and could perhaps even lead to reduced length of stay. Sleep is known to be closely connected to physical and mental health, and yet hospital environments are far from conducive to high quality rest. Noise, light, disturbances for treatment or tests, other patients, staff noise and temperature can all reduce the odds of a good night’s sleep. Overnight observations can also be extremely disruptive. At some trusts, efforts are being made to address this situation. The ultimate aim? Not only to improve the patient experience, but to potentially the speed with which they heal–so reducing the likes of length of stay. Others, meanwhile, are exploring whether supporting better sleep could even reduce the need for hospital admission in the first place.
  22. News Article
    Norah Bassett was hours old when she died in 2019, after multiple failings in her care. What can be learned from her heartbreaking loss? The maternity unit at the Royal Hampshire county hospital in Winchester was busy the evening when Charlotte Bassett gave birth. When the night shift came on duty, a midwife introduced. “She was very brusque,” Charlotte, 37, a data manager, remembers. “She said, ‘We’ve got too many people here. I’ve got this and this to do.’” Charlotte tried to breastfeed Norah, but she wasn’t latching. The midwife told Charlotte to cup feed her with formula. She didn’t stay to watch. Charlotte poured milk from a cup into Norah’s rosebud mouth. Blood came out. It was staining the muslin. The midwife didn’t seem concerned. “I was drowning my child, who was drowning in her own blood. And there was no one there to say: this isn’t normal,” Charlotte says. The Health Services Safety Investigations Body (now HSSIB but at the time known as HSIB), which investigates patient safety in English hospitals, produced a report into Norah’s care in 2020. One sentence leaped out to Charlotte and her husband James. “An upper airway event (such as occlusion of the baby’s airway during skin-to-skin) may have contributed to the baby’s collapse.” In other words, it was possible that Charlotte might have smothered her daughter. “So Charlotte spent four years in agony,” says James, “thinking it was her.” Dr Martyn Pitman remembers the night Norah died, because it was unusual. A crash call, for a baby born to a low-risk mother. It played on his mind, because eight days earlier, on 4 April 2019, Pitman, a consultant obstetrician and gynaecologist, had presented proposals for enhanced foetal monitoring to a meeting of the maternity unit’s doctors and senior midwives. Pitman, 57, who is an expert in foetal monitoring, felt the proposals would prevent more babies suffering brain injuries at birth. “We’re not that good at detecting the high-risk baby, in the low-risk mum,” he says. Another doctor would later characterise the meeting as “hideous … hands down the worst meeting I’ve ever been to. Martyn … was being set upon.” A midwife felt the animosity in the room was “personal towards Martyn”, and was “appalled” by the “unprofessionalism that I saw from my midwifery colleagues”. James and Charlotte join an unhappy club: a community of parents whose children died young, after receiving poor care, and were told their deaths were unavoidable, or felt blamed for them. “I’ve spoken to so many families,” says Donna Ockenden, who authored a 2022 report into Shrewsbury’s maternity services, “who have been blamed for the eventual poor outcome in their cases. This has included being blamed for their babies’ death.” She has also met the families of women blamed for their own deaths. “This never fails to shock me,” she says. Read full story Source: The Guardian, 26 March 2024
  23. News Article
    Ministers are being urged to roll out a better testing regime for one of the country’s biggest killers, with the most recent figures showing death rates for chronic obstructive pulmonary disease more than three times higher in some of the most deprived areas of the country. More than 20,000 people a year in England die from chronic obstructive pulmonary disease. The most significant cause of COPD is smoking, but a significant proportion of cases are work-related, triggered by exposure to fumes, chemicals and dust at work. Figures from the Office for National Statistics reveal that death rates from the disease are significantly higher in more deprived areas of the country. The NHS is rolling out targeted lung screening across England for people aged between 55 and 74 who are current or former smokers. The charity Asthma + Lung UK says the checks will identify many people who may have COPD, but there is no established protocol for them to be diagnosed and given appropriate treatment and support. Dr Samantha Walker, interim chief executive at Asthma + Lung UK, said: “Once targeted lung health checks are fully rolled out, millions of people could be told they have an incurable lung disease like chronic obstructive pulmonary disease, but they won’t be given a firm diagnosis or signposted to the right support, which is simply unacceptable. “What we need to see is a national referral pathway in place for those people who show signs of having other lung conditions as part of this screening process to ensure that people with all suspected lung conditions get the diagnosis and treatments that they deserve. We know that people with lung disease will live better, fuller lives with an earlier diagnosis.” Read full story Source: The Guardian, 24 March 2024
  24. News Article
    A&E staff are unable to properly look after the most vulnerable mental health patients or treat them with compassion because emergency departments are so overwhelmed, top medics have warned. An exclusive report shared with The Independent shows more than 40% of patients who needed emergency care due to self-harm or suicide attempts received no compassionate care while in A&E, according to their medical records. The data, collated by the Royal College of Emergency Medicine (RCEM), prompted a warning from top doctor Dr Adrian Boyle that mental health patients are spending far too long in A&E – where they are cared for by staff who are not specifically trained for their needs – before being moved to an appropriate ward. Dr Boyle, who is president of the RCEM, said there had been some progress in improving care for a “historically disadvantaged” group, but added: “Patients with mental health problems are still spending too long in our emergency departments, with an average length of stay of nearly 10 hours and this has not really improved. “An emergency department is frequently noisy and agitating, the lights never go off and cannot be described as an environment that promotes recovery.” When a patient goes to A&E after a self-harm attempt, they should receive an assessment by a clinician into the type of self-harm, reasons for it, future plans or further suicidal thoughts. The college said it indicates a “significant gap” in the NHS’ ability to provide holistic care for mental health patients with complex needs and warned “urgent” improvements are needed. Read full story Source: The Independent, 25 March 2024
  25. Content Article
    In this report, Patient Safety Learning analyses the results of questions in the NHS Staff Survey 2023 specifically relating to reporting, speaking up and acting on patient safety concerns. It raises questions as to why there has been so little progress despite policy intention in this area. It concludes by setting out the need to improve the implementation, monitoring and evaluation of work seeking to create a safety culture across the NHS. This article contains a summary of the report, which can be read in full here or from downloading the attachment below.
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