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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
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    The Everywoman festival is a one day event aimed at all women over the age of 16 and aims to empower women to understand what is normal and when to seek help for issues that can affect 90% of women at some point in their life. The festival combines more than 40 workshops and 6 themed seminar sessions with a fun, relaxed environment with art workshops, food and drink, music and charity stands. Themes are wide ranging and include periods and endometriosis, pelvis pain and bladder, childbirth injury, menopause and sexual wellbeing. Additional drop in sessions to meet the consultant experts as well as book readings and signings will be available on the day. The Everywoman Festival will be held in the heart of Cardiff in the beautiful venue of Insole Court. It will feature a range of interactive workshops and talks from leading health experts. Attendees will have the opportunity to learn about everything from nutrition and fitness to mindfulness through art. For those who are looking for something a little more active, there will be a variety of fitness classes and workshops taking place throughout the day. From seated yoga, Pilates to Belly dancing and dancing lessons from Heels empowerment, there's something for everyone, regardless of their fitness level. Charities attending with stalls and information include Coppa feel, Endometriosis UK, Womens Aid, the Menstrual project and Fair Treatment for Women of Wales. Health stalls from Muslim Doctors Cymru, Medtronic, Mcgregor, THD will be on hand to provide information and signpost for everything from your bladder and bowels, childbirth to high blood pressure. Some of the highlights of the festival are the wellness market, where attendees can shop for a wide variety of health and wellness products and in the creative market products from artists such as Black and Beech, Melin Trygwynt and Eliza Eliza. Further tickets and information Follow on instagram @Theeverywomanfestival A5leaflet Everywoman (2).pdf
  2. Content Article
    Five professionals explore and discuss safe patient handling. Safe patient handling is essential for encouraging mobility for the patient and maintaining their skin integrity while not forgetting the impact on the healthcare worker. Each health care specialty has differing challenges, and this podcast explores some of these and look to see if an interprofessional care approach can help drive safer care and better outcomes.
  3. Content Article
    This webinar shares the findings of a co-production project in Nottingham and Nottinghamshire Integrated Care Board (ICB) to remove barriers to shared decision making. The partners in the project were the ICB’s Personalised Care Team, the My Life Choices lived experience panel, the Patient Information Forum (PIF) and the Patients Association. Over the course of six co-production meetings, they developed simple resources to support patients and professionals to have better shared decision making conversations. Speakers discuss practical solutions to help patients and professionals get the most from limited appointment times which can be applied nationally.
  4. Content Article
    The implementation and continuous improvement of patient safety learning systems (PSLS) is a principal strategy for mitigating preventable harm to patients. Although substantial efforts have sought to improve these systems, there is a need to more comprehensively understand critical success factors. This study aims to summarise the barriers and facilitators perceived by hospital staff and physicians to influence the reporting, analysis, learning and feedback within PSLS in hospitals.
  5. News Article
    A world-renowned cancer centre hit by whistleblowing concerns over alleged bullying has been downgraded by the health watchdog. The Care Quality Commission (CQC) told The Christie NHS Foundation Trust in Manchester it "requires improvement" in safety and leadership. A former trust nurse told the BBC leaders had intimidated staff to stop them voicing concerns to inspectors. Rebecca Wight worked at The Christie - Europe's largest cancer centre - from 2014 but quit her role as an advanced nurse practitioner in December, claiming her whistleblowing attempts had been ignored. She told BBC Newsnight the trust had attempted to manipulate the inspection by intimidating those who wished to paint an honest picture. Roger Kline, an NHS workforce and culture expert from Middlesex University Business School, told BBC Newsnight there was a culture at The Christie which was "unwelcoming of people raising concerns". He said: "The trust response is more likely... to see the person raising the concerns as the problem rather than the issues they have raised," adding this was "not good for patient care". Read full story Source: BBC News, 12 May 2023
  6. News Article
    Artificial intelligence (AI) could be “transformational” in improving heart attack diagnosis to reduce pressure on emergency departments, a new study suggests. Doctors could soon use an algorithm developed using AI to diagnose heart attacks with better speed and accuracy than ever before, the research from the University of Edinburgh indicates. It could also help tackle dangerous inequalities in diagnosing the condition, scientists suggest. Researchers found that, compared to current testing methods, the algorithm called CoDE-ACS was able to rule out a heart attack in more than double the number of patients, with an accuracy of 99.6%. Nicholas Mills, British Heart Foundation (BHF) professor of cardiology at the Centre for Cardiovascular Science, University of Edinburgh, who led the research, said: “For patients with acute chest pain due to a heart attack, early diagnosis and treatment saves lives. “Unfortunately, many conditions cause these common symptoms, and the diagnosis is not always straight forward. “Harnessing data and artificial intelligence to support clinical decisions has enormous potential to improve care for patients and efficiency in our busy emergency departments.” Read full story Source: The Independent, 11 May 2023
  7. News Article
    New weight loss drugs such as Wegovy will not be a “silver bullet” in tackling obesity, the World Health Organization (WHO) has warned. Francesco Branca, WHO director of food and nutrition safety, said weight loss drugs must be used alongside a healthy diet and exercise. Ms Branca’s comments come as the health body conducts its first review of obesity management guidelines in two decades. Semaglutide, marketed as Wegovy by drugmaker Novo Nordisk, is an appetite suppressant drug that has been approved by the UK medicines regulator and described by some as a “game changer” in helping people to shed weight. People will only be given Wegovy on prescription as part of a specialist weight management service involving input from several professionals and for a maximum of two years. Some experts described the decision as a “pivotal moment” for the treatment of people living with obesity but others warned that the drug is not a “quick fix”. Read full story Source: The Independent, 12 May 2023
  8. News Article
    Monkeypox is no longer a global public health emergency, the World Health Organization (WHO) has said, almost a year after the threat was raised. The virus is still around and further waves and outbreaks could continue, but the highest level of alert is over, the WHO added. The global health body's chief Tedros Adhanom Ghebreyesus called on countries to "remain vigilant". More than 87,000 cases and 140 deaths have been reported from 111 countries during the global outbreak, according to a WHO count. But almost 90% fewer cases were recorded over the last three months compared with the previous three-month period, meaning the highest level of alert is no longer required, Tedros said. Read full story Source: BBC News, 11 May 2023
  9. News Article
    The death rates for black women in childbirth were revealed in a recent report from MPs and were described as “appalling”, yet action, not words, are needed for what could be considered breaches of the Human Rights Act. Ministers are not giving priority to reducing the gap in health inequalities, write Nicola Wainwright and Suleikha Ali in a commentary to the Times. "If the response to the review is foot-dragging from the government and senior health service officials, then legal action may be the only way to draw focus to this issue and to try to reduce the number of ethnic minority women and babies dying unnecessarily." The report, published by the women and equalities committee last month, highlights the “glaring and persistent” disparities faced by ethnic minority women compared to their white counterparts with regards to pregnancy and birth. However, these same disparities have been known and reported on for 20 years, while progress on improving the situation has been shockingly slow. Read full story (paywalled) Source: The Times, 11 May 2023
  10. Community Post
    Hi @Illumi123 So sorry to hear of your horrific experience when you went to get an IUD fitted. No-one should have to experience this type of pain. Although many women have only mild discomfort when they have an IUD, as you can read from this thread, many like yourself have a much worse experience. If possible, please do speak to a trusted friend or adult about you concerns and experience. We would also encourage you to go and see a healthcare professional, potentially with a friend or trusted adult for support, to discuss your concerns and the pain relief options that are available to you. Having more information may help you feel in a stronger position when the time comes to have your IUD removed. Also, if possible through school or the community, it may be helpful to speak to a counsellor about how you may be able to manage your fears in relation to this if this is something you would feel comfortable doing. Please continue following this thread as there may be a healthcare professional or patient who has gone through something similar who could advise you further on the options available to you in the US.
  11. News Article
    Thrombosis UK has warned that deaths involving blood clots are higher than expected as it called for more transparency over the work hospitals are doing to reduce the risk for patients. Before the pandemic hit, hospitals were regularly publishing data on the number of patients who had been risk assessed for blood clots. In March 2020, the NHS in England took the decision to suspend the data collection on venous thromboembolism (also known as VTE) risk assessments to “release capacity in providers and commissioners to manage the Covid-19 pandemic”. But the data collection and publication is yet to resume. The charity said the data shows how many VTE cases are missed in hospitals. One bereaved man described how his mother died last year after the condition was missed. Tim Edwards, 42, said healthcare workers missed signs of the condition while Jennifer Edwards, 74, was in hospital on the south coast. Despite having many symptoms of a pulmonary embolism she was discharged home and died three days later. Mr Edwards said: ““My mother’s symptoms were missed from her admission to hospital right up to her time in the cardiology department. “She was discharged and passed away three days after phoning the NHS with shortness of breath. She should not have died. I took it upon myself to enquire about the circumstances surrounding her death and was overwhelmed by the lack of care taken. “Sadly, I know this is not an isolated case.” Read full story Source: Wales Online, 12 May 2023 Further reading on the hub: Pulmonary embolism misdiagnosis – a systemic problem (a blog from Tim Edwards) Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (Tim Edwards) Jenny, and why we must learn from her misdiagnosis of pulmonary embolism National Voices: Pulmonary embolism misdiagnosis - a blog by Helen Hughes.
  12. News Article
    A former NHS chief executive is suing her employer, saying she was "bullied, harassed, intimidated and undermined" by the hospital trust's chairman. In legal papers, seen by BBC News, Dr Susan Gilby alleges she was effectively unfairly dismissed by the Countess of Chester NHS Foundation Trust, after she made a formal complaint. Dr Gilby claims the chairman was "highly aggressive and intimidatory" in meetings, that he banged his hand on a desk to emphasise his point, and oversaw a climate where "offensively sexist comments and ferocious and repetitive criticisms" were made by either him or his associates. Dr Gilby's complaint accuses the chairman of putting finance above patient safety at the hospital trust She made a formal whistle-blowing complaint against the chairman in July 2022, raising her concerns about his behaviour to both the trust and NHS England. The trust responded to her concerns, Dr Gilby claims, by proposing that she be seconded to a senior advisory role within NHS England on the condition she withdrew her allegations. Read full story Source: BBC News, 12 May 2023
  13. News Article
    The NHS waiting list hit a record 7.3 million incomplete pathways in March, according to new official data, as trust bosses gear up to clear the circa 95,000 patients who have waited over 65 weeks. NHS England also confirmed in its monthly statistical update that there remained around 10,000 patients on the waiting list who had breached 78 weeks despite a target to clear this cohort by April, as HSJ revealed would be the case in March. It instead hoped these will be cleared by June or July. Ten trusts are responsible for around half of the 78-week breaches, with Manchester University Foundation Trust recording the most on 969, University Hospitals Leicester Trust reporting 837 and Royal Devon University Healthcare FT on 695. NHSE chief executive Amanda Pritchard said the NHS “is making great strides on long waits… in the face of incredible pressure [and this] is testimony to the hard work, drive and innovation of frontline colleagues”. Read full story (paywalled) Source: HSJ, 11 May 2023
  14. News Article
    An autistic girl aged 16 spent nearly seven months in a busy general hospital due to a lack of suitable children's mental health services in England. The teenager, called Molly, spent about 200 days living in a side-room of a children's ward at the Queen Alexandra Hospital in Portsmouth. It is not a mental health unit. Experts say a general hospital was not the right place for her, but she had nowhere else to go because of a lack of help in the community. Agency mental health nurses were brought in because she needed constant, three-to-one observations to keep her safe. Her family says security guards were also often stationed outside her room. Like many autistic people, Molly finds dealing with noise difficult. The clamour of the hospital overloaded her senses and her behaviour sometimes became challenging. She was restrained numerous times. A spokesperson for Hampshire and Isle of Wight Integrated Care System (ICS) said it was sorry Molly "did not receive care in an environment better suited to her needs", adding: "Molly's safety has always been our priority." Campaigners describe the shortage of appropriate support for people with autism as a human rights crisis. Read full story Source: BBC News, 10 May 2023
  15. News Article
    ICBs should ensure there are ‘formal escalation routes’ in place for GPs after 25 daily clinical contacts, the BMA has said in new guidance. From next week (15 May), GP practices are contractually required to offer an ‘appropriate response’ to patients the first time they get in contact, by offering them an appointment or redirection, rather than asking them to call back at a different time. While GP leaders warned this would lead to increased pressure on NHS 111 and A&E, NHS England attempted to clarify in this week’s recovery plan that GPs should only redirect patients in ‘exceptional circumstances’. It also said practices should inform their ICB on each such occasion. However, conflicting BMA guidance has now been published, warning that practices attempting to adhere to the new requirement ‘may do so at the expense of clinician wellbeing and patient safety’. It reiterates the GP Committee for England’s safe working guidance recommending that clinicians have no more than 25 clinical contacts per day because anything beyond this "can lead to decision fatigue, clinical errors and patient harm, and clinician burn out". Read full story Source: Pulse, 11 May 2023
  16. News Article
    A leading health panel in the USA has recommended the age at which women are regularly screened for breast cancer should be cut from 50 to 40. The US Preventive Services Task Force (USPSTF) said an extra 20 million women in their forties would benefit from a mammogram every two years. The change would save 20% more lives, according to the USPSTF, which has drafted the proposal in response to rising rates among middle-aged women. Currently, all women in the USA aged 50 to 74 are advised to get checked via a mammogram every two years. The number of new breast cancer cases is rising roughly two percent every year, John Wong, an internist and professor of medicine at Tufts University School of Medicine, who is on the task force, told the Washington Post. Dr Wong said: "It is now clear that screening every other year starting at age 40 has the potential to save about 20 percent more lives among all women, and there is even greater potential benefit for black women, who are much more likely to die from breast cancer." Read full story Source: Mail Online, 9 May 2023
  17. News Article
    A simple intervention to detect and treat postpartum haemorrhage could dramatically cut maternal mortality and morbidity worldwide, a large trial led by the University of Birmingham has shown. Use of a special drape to measure blood loss during childbirth and rapid deployment of a “bundle” of existing treatments reduced severe bleeding, the need for laparotomy, or maternal death by 60% in a study done in 80 hospitals across Kenya, Nigeria, South Africa, and Tanzania. Reporting the results in the New England Journal of Medicine, the researchers said that postpartum haemorrhage was detected in 93.1% of patients in the intervention and in 51.1% of those receiving usual care. Read full story (paywalled) Source: BMJ, 10 May 2023
  18. News Article
    Figures showing the risk of maternal death being almost four times higher among women from black ethnic minority backgrounds compared with white women in the UK have been published. The figures, which relate to 2019 - 2021, have been released by MBRRACE-UK, a collaboration involving the University of Leicester. The MBRRACE-UK collaboration (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries), led from Oxford Population Health's National Perinatal Epidemiology Unit, looked at data on women who died during, or up to six weeks after, pregnancy between 2019 and 2021 in the UK. The report showed the risk of maternal death in 2019 - 2021 was almost four times higher among women from black ethnic minority backgrounds compared with white women. Marian Knight, professor of Maternal and Child Population Health at Oxford Population Health and maternal reporting lead, said: "Persistent disparities in maternal health remain. "It is critical that we are working towards more inclusive care where women are listened to, their voices are heard, and we are acting upon what they are telling us." Read full story Source: BBC News, 11 May 2023
  19. News Article
    The first non-prescription birth control pill in the US is on the way to approval, after a thumbs-up from an advisory committee of drug regulators. The Food and Drug Administration (FDA) panel's unanimous vote is not binding, but means the agency is likely to formally approve the drug this summer. Opill has been available, but only by prescription, for the past 50 years. The push for over-the-counter access in the US comes amid Republican-led efforts to restrict access to abortion and contraception at the national and state level. Advisors on the panel said they were mostly confident women of all ages would use the drug as appropriate without first consulting a healthcare provider. "In the balance between benefit and risk, we'd have a hard time justifying not taking this action," said chairwoman Maria Coyle, an Ohio State University pharmacist. "The drug is incredibly effective, and I think it will be effective in the over-the-counter realm just as it is in the prescription realm." Read full story Source: BBC News, 10 May 2023
  20. Content Article
    Health literacy, defined as an individual's ability to access, understand, and use health information to make informed decisions about their health and healthcare, plays a critical role in determining health outcomes. Wider determinants of health, on the other hand, refer to a range of social, economic, and environmental factors that influence an individual's health status. This article aims to explore the relationship between health literacy and the wider determinants of health, and how understanding this connection can contribute to more effective population health management and health equity.
  21. News Article
    Online pharmacies operating in the UK are approving and dispatching prescriptions of controversial slimming jabs for people of a healthy weight, a Guardian investigation has found. Some pharmacies appear to be issuing prescriptions of such medications to people who lie about their body mass index (BMI) on an online form. In one case a reporter was issued a prescription after accurately saying their BMI was about 20. A healthy BMI lies between 18.5 and 24.9. The findings have raised alarm among eating disorder charities, which have warned that weight-loss medications should only be sold under the strictest conditions. Their concern has prompted calls for online pharmacies to employ stronger health checks and screening for eating disorders. Read full story Source: The Guardian, 10 May 2023
  22. News Article
    Hundreds of children who manage their type 2 diabetes by regularly pricking their finger can now monitor their glucose levels using automated sensors, the government’s expert health advisers have announced. Doctors and nurses in England, Wales and Northern Ireland have been advised they can now give glucose monitoring devices to children with type 2 diabetes who currently use the more intrusive finger-prick testing methods, the National Institute for Health and Care Excellence (NICE) said on Thursday. The health minister Helen Whately said that offering children the devices would relieve a burden and “empower them to manage their condition more easily”. She said: “Type 2 diabetes is increasingly being diagnosed in children, many of whom face the constant stress of needing to monitor their blood glucose levels by finger-prick testing – often multiple times a day – just to stay healthy and avoid complications.” The NICE committee that reached the decision heard that children found finger pricking to check their glucose levels several times a day “burdensome”, “tiring” and “stressful”. The devices, which give a continuous stream of real-time information on a smartphone, have already been recommended for children with type 1 diabetes, a less aggressive form of the disease. Read full story Source: The Guardian, 11 May 2023
  23. Content Article
    Brazil's community health workers (CHWs) have been critical in the effort to connect a majority of Brazilians to with primary healthcare, and have delivered significant impact across the country. They have reduced some of Brazil's socioeconomic and geographic inequities in access to healthcare and broadly improved health and social indicators. Find out more why they are exemplars in global health.
  24. News Article
    Staff shortages forced pharmacies to shut for 100,000 hours in a year, new figures show, just as the government has unveiled plans to shift more GP work their way. The data, shared exclusively with The Independent by the organisation which represents pharmacies in England, also showed that almost 1,000 establishments closed for good between October 2016 and November 2022. The Pharmaceutical Services Negotiating Committee (PSNC) figures revealed that pharmacies in the most deprived areas were more likely to shut permanently due to lack of staff, with areas such as Birmingham and Manchester among the worst affected. The figures come as the government announced plans on Tuesday to allow pharmacists to prescribe medicines for conditions including earache, sore throats and urinary tract infections without GP involvement. However, experts have said the plans are unlikely to significantly reduce pressure on GP practices as prescriptions for these conditions make up just 3 per cent of all appointments. And the King’s Fund health think tank warned of the potential for a postcode lottery – saying some pharmacies will not be able to offer the services because they may not have access to diagnostic tools, or sufficient staff and consultation rooms. Read full story Source: The Independent, 10 May 2023
  25. Content Article
    Should new draft legislation around the use of mesh in women regarding incontinence or prolapse and a new guidance on a national registry meaning every woman choosing mesh in the future must be logged on a database be extended? Haydn Wheeler argues that a broader database is in need.
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