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Patient Safety Learning

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  1. Content Article
    The Academy of Medical Royal Colleges and the University of Warwick have developed this NHS Patient Safety syllabus to complement it as the basis for education and training for staff throughout the NHS.
  2. Content Article
    The Patient Safety Authority (PSA) is an independent state agency that collects reports of patient safety events from Pennsylvania healthcare facilities. Pennsylvania is the only state that requires acute care facilities to report all incidents of harm (serious events) or potential for harm (incidents). Long-term care facilities report infections into the Pennsylvania Patient Safety Reporting System (PA-PSRS). The PSA analyses those reports to prevent recurrence—either by identifying trends unapparent to a single facility or flagging a single event that has a high likelihood of recurrence— and disseminates that information through multiple channels. Here is the PSA's 2022 Annual Report.
  3. News Article
    Every time a mistake is made in a healthcare setting, there can be serious repercussions. Patients may suffer lifetime injuries or even pay the ultimate price for someone else's mistake. Hospitals may wind up paying the price literally — financially and legally — and suffer costly public reputation troubles in the aftermath. Increased patient loads combined with the workforce shortage and often decreasing financial resources have created "chaos" in hospitals, said Doug Salvador MD, chief quality officer at Baystate Health in Springfield, Mass. Safety watchdog organizations, including The Joint Commission and The Leapfrog Group, have reported the result of that chaos: soaring cases of preventable medical errors. The solution, he and several other sources who spoke with Becker's said, is to create standard operating procedures in every department, at every step of the patient journey. These SOPs are more than lists of guidelines; they require strict adherence and limited room for error thanks to built-in cross-check points. And, when instituted properly, they highlight system flaws in real time by creating what Dr. Salvador called "situational awareness." Situational awareness, he added, keeps front-line healthcare professionals on top of their safety game. Read full story Source: Becker's Healthcare, 9 May 2023
  4. News Article
    AI could harm the health of millions and pose an existential threat to humanity, doctors and public health experts have said as they called for a halt to the development of artificial general intelligence until it is regulated. Artificial intelligence has the potential to revolutionise healthcare by improving diagnosis of diseases, finding better ways to treat patients and extending care to more people. But the development of artificial intelligence also has the potential to produce negative health impacts, according to health professionals from the UK, US, Australia, Costa Rica and Malaysia writing in the journal BMJ Global Health. The risks associated with medicine and healthcare “include the potential for AI errors to cause patient harm, issues with data privacy and security and the use of AI in ways that will worsen social and health inequalities”, they said. One example of harm, they said, was the use of an AI-driven pulse oximeter that overestimated blood oxygen levels in patients with darker skin, resulting in the undertreatment of their hypoxia. Read full story Source: The Guardian, 10 May 2023
  5. News Article
    Lip fillers have grown increasingly popular but the industry is "like the wild west", experts warn, with many patients left in pain and embarrassed by their appearance. As Harriet Green left a salon after getting an injection to add volume to her lips, she was reassured the excess swelling would go down. But three months later her lips were still so bloated she could not close her mouth properly. The 22-year-old from Acle in Norfolk needed three corrective procedures - costing a total of more than £700 - to get them back to normal. Dr Saba Raja, a GP who runs her own aesthetics clinic in Norwich, says she is increasingly having to correct treatments which have gone wrong, describing the experience as "really distressing". "Every month I'm getting enquires from young girls who have gone to a non-medical practitioner for lip or tear trough fillers under the eye and had complications. "They often try to contact the practitioner but due to lack of training they are unable to deal with the complications. It is becoming more and more of a problem." Dr Raja describes the industry as "like the wild west", with people injecting patients "out of the back of their cars" and in kitchens. "Anti-wrinkle injections (Botox) are prescription-only but the injector can be anybody who has been on a day course. Dermal filler (for the lips and face) is not even a prescription-only medication, you can buy it off any website," she says. "A lot of non-medical practitioners are buying cheap filler online, with no idea where it has come from. We really need strict regulations and minimum training standards." Read full story Source: BBC News, 9 May 2023
  6. News Article
    Patients, or carers of patients, who carry Emerade 300 or 500 microgram adrenaline auto-injector pens should immediately contact their GP to obtain a prescription for, and be supplied with two auto-injectors of a different brand. Pharmacists and pharmacy teams can also help with obtaining new prescriptions and dispensing of new pens. Patients or carers should then return all Emerade 300 and 500 micrograms auto-injectors to their local pharmacy. Patients should only return their Emerade pens when they have received a replacement from their pharmacy which will be an alternative brand - either EpiPen or Jext. They should ensure they know how to use the replacement pen, as each brand of pen works differently. Patients should ask their doctor, pharmacist, or nurse for help with this. Instructions are included inside the pack, along with details of the manufacturer’s website that also provides information, including videos, on how to use a new EpiPen or Jext adrenaline pen. This precautionary recall is because some 300 microgram and 500 microgram Emerade auto-injector pens may rarely fail to activate if they are dropped, meaning a dose of adrenaline would not be delivered. Premature activation has also been detected in some of the 300 microgram and 500 microgram pens after they have been dropped, meaning that a dose of adrenaline is delivered too early. The activation failure and premature activation was detected during a design assessment conducted by the manufacturer and therefore means there is a potential for some 300 microgram and 500 microgram Emerade pens to fail during use after having been dropped. Read MHRA Press Release. 9 May 2023
  7. Content Article
    Increasing numbers of people are at risk of developing frailty. People living with frailty are experiencing unwarranted variationin their care. This toolkit will provide you with expert practical advice and guidance on how to commission and provide the best system wide care for people living with frailty.
  8. News Article
    School-leavers could receive on-the-job training as part of an attempt to help address NHS workforce shortages, under plans to allow tens of thousands of doctors and nurses to join the health service via apprenticeships. Up to 1 in 10 doctors and a third of nurses could be trained through this vocational path in the coming years under the NHS workforce plan. The NHS’s doctor apprenticeship scheme is due to start in September, where medics in training will be able to earn money while they study. The concept was first introduced as an alternative route into medicine circumventing the standard undergraduate or graduate university programmes. Dr Latifa Patel, workforce lead for the British Medical Association, said innovative approaches to education and training are welcome but there were huge question marks over how far medical apprenticeships can solve the recruitment crisis. Patel said: “We don’t know if medical schools and employing organisations are going to be able to produce medical degree programmes to meet individual apprenticeship needs while also meeting the same high standards of training experienced by traditional medical students. “We have little evidence on whether the apprentice model will work at scale, and whether employers will want to take the investment risk with no guarantee of a return." Read full story Source: The Guardian, 10 May 2023
  9. News Article
    Up to 10 junior doctor posts will be reinstated at a small district general hospital after regulators agreed it had improved its learning environment. In 2021, Health Education England removed 10 doctors from Weston Hospital over concerns they were being left without adequate supervision on understaffed wards. The unusual move prompted University Hospitals Bristol and Weston Foundation Trust to launch a “quality improvement approach” to improve its learner and clinical supervision environment. The regulator said the trust had made significant improvements that included: Better staff engagement with the trust leadership at all levels. Better clinical supervision, particularly around shift handovers and senior oversight of clinical decisions. Better learner experience in new training settings in rheumatology and intensive care medicine. Read full story (paywalled) Source: HSJ, 10 May 2023
  10. News Article
    Antidepressants commonly used to treat chronic pain lack evidence as to whether or not they work, researchers have said, declaring the situation a global public health concern. Chronic pain, typically defined as pain lasting three months or more, is a widespread problem affecting up to one in three people, with conditions ranging from osteoarthritis to fibromyalgia. While exercise is often recommended, this is difficult for some patients, while there are concerns that opioids and other painkillers such as aspirin and paracetamol could do more harm than good. Increasing numbers of patients are prescribed antidepressants to treat their pain, with hundreds of thousands in the UK estimated to be taking amitriptyline. Antidepressants affect chemicals known as neurotransmitters, which is how they are thought to relieve pain. But a new Cochrane review, led by Prof Tamar Pincus, professor in health psychology at the University of Southampton, has revealed there is little evidence whether or not amitriptyline and many other common antidepressants work when it comes to tackling chronic pain. “The fact that we don’t find evidence whether it works or not, is not the same as finding evidence that it doesn’t work,” she said. “We don’t know. The studies simply are not good enough.” Read full story Source: The Guardian, 10 May 2023
  11. News Article
    Delayed health checks among people with diabetes may have contributed to 7,000 more deaths than usual in England last year, a charity report suggests. The routine checks help cut the risk of serious complications like amputations and heart attacks. Diabetes UK says too many people are still being "left to go it alone" when managing their challenging condition. There are more than five million people in the UK living with diabetes, but around 1.9 million missed out on routine vital checks in 2021-22, Diabetes UK says. Disruption to care during the pandemic is likely to be a factor in the current backlog, which may be leading to higher numbers of deaths than usual in people with diabetes, it says. Between January and March 2023, for example, there were 1,461 excess deaths involving diabetes - three times higher than during the same period last year. "Urgent action is needed to reverse this trend and support everyone living with diabetes to live well with the condition," the report says. Read full story Source: BBC News, 10 May 2023
  12. Content Article
    Missed checks, disrupted care and health inequalities have been revealed in a new report from Diabetes UK looking at the state of diabetes care in England. The report reveals that less than half (47%) of people living with diabetes in England received all eight of their required checks in 2021-22, meaning 1.9 million people did not receive the care they need.  It is calling for urgent action to address the routine diabetes care backlog and prevent avoidable deaths of people living with diabetes. 
  13. Content Article
    This white paper from CEMBooks aims to unpick some of the deeper issues surrounding bed block and emergency department crowding from the perspective of a frontline medic with two decades of emergency and flow management experience. It aims to provide a greater understanding of the factors influencing the current situation and the measures used to define it followed by some practical implementable solutions.
  14. Content Article
    Compassionate leadership builds connection across boundaries, ensuring that the voices of all are heard in the process of delivering and improving care. In order to nurture a culture of compassion, organisations require their leaders – as the carriers of culture – to embody compassion and inclusion in their leadership. Where leaders model a commitment to high-quality and compassionate care, this impacts everything from clinical effectiveness and patient safety to staff health, wellbeing and engagement. The King's Fund's work, through courses, blogs and articles, explores the role of, and supports, leaders in creating a culture of compassion and inclusion.
  15. Content Article Comment
    Hi Anne I'm sure @SamFreemanCarney and Parkinson's UK would be happy for you to share the video and information with your colleagues.
  16. Content Article
    Judy Walker summarises four tools that can be used for the Patient Safety Incident Response Framework (PSIRF), explaining what they are and the strengths and weaknesses of each: SWARM Huddle MDT Review After Action Review Patient Safety Incident Investigation (PSII).
  17. News Article
    In an email to staff today (9 May 2023) NHS England (NHSE) have confirmed that to meet the deadline for implementing the new Learn From Patient Safety Events (LFPSE) service, Trusts will only need to ensure this is underway by the 30 September 2023, rather than fully implemented. LFPSE is a new central national service for recording and analysing patient safety events that occur in healthcare. Some NHS organisations are now using this system, instead of the National Reporting and Learning System (NRLS), and all organisations will be expected to transition to this. The original date for Trusts to implement LFPSE was the 31 March 2023. However, in response to concerns about the achievability of this deadline, on the 18 October NHSE announced an optional six-month extension, meaning that Trusts needed to deploy the new system by the 30 September 2023. Today’s email to NHS staff noted that some Trusts “are still anticipating challenges with the time scales”. Responding to this, NHSE clarified that provided the LFPSE transition within organisations Local Risk Management Systems was underway by the end of September, and that application of the guidance to configure formals and fields was being actively worked on, this milestone should be considered as having been met. Commenting on this Helen Hughes, Chief Executive of charity Patient Safety Learning, said: “This is a welcome announcement by NHS England, reducing the immediate pressure on staff who had raised serious concerns on the ability to have LFPSE configured and ready to submit events by the 30 September deadline. This flexibility will ensure that the new LFPSE service has a stronger chance of successful transition and to enable patient safety improvement”.
  18. News Article
    Knocking on doors to check on people's health and catch problems before they escalate is common practice across Brazil. But could that approach work in the UK? Comfort and Nahima are two out of four door-knockers on round Churchill Gardens, a council estate in the Pimlico neighbourhood of London, visiting residents as part of a proactive community healthcare pilot. They can help with anything from housing issues which impact health, such as overcrowding, or pick up the early signs of diabetes by chatting informally to residents about their lifestyle. These community health workers are partly funded by the local authority and partly by the NHS so they can co-ordinate between the local GP surgery and other social services. Local GP Dr Connie Junghans-Minton says the proactive approach had led to fewer requests for appointments The National Institute for Health Research helped crunch the data from the pilot. Households which had been visited regularly were 47% more likely to have received immunisations and 82% more likely to have taken up cancer screening, compared to other areas. The idea to import this model to the UK came from Dr Matthew Harris, a public health expert at Imperial College London who worked as a GP in Brazil for four years. There, community health workers have been credited with achieving a drop of 34% in cardiovascular deaths. "In Brazil they have scaled this role to such degree that they have 270,000 community health workers across the whole country, each of which looks after 150 households, visiting them at least once a month," Dr Harris said. "They've seen extraordinary outcomes in terms of population health in the last two or three decades. We think we've got a lot to learn from that." Read full story Source: BBC News, 9 May 2023
  19. News Article
    The vast majority of GP practices should allow patients to manage their care through the NHS App in less than a year, according to the primary care recovery plan published by government and NHS England today. The plan says patients at more than 90% of practices should be able to use the app to see their records, book appointments and order repeat prescriptions by March 2024. Currently, only around 20% of practices offer this, and data revealed recently by HSJ suggested use of the app is flatlining. The plan says: “We want the public to have access to health information they can trust, find local services, and use the NHS App where this is their preference to see their medical records, order repeat prescriptions, manage routine appointments with their practice or local hospital and see messages from their practice. “The NHS App ambitions are already a reality for people registered with around 20% of practices, so this plan focuses on how to increase that to over 90% by March 2024.” Read full story (paywalled) Source: HSJ, 9 May 2023
  20. News Article
    Steve Barclay has refused to approve about 30 proposed community diagnostic centres (CDCs) – designed to speed up cancer treatment – unless they can be delivered in 2023, HSJ has learned. Mr Barclay’s stance means the CDCs which were due to open in 2024, and which officials say cannot be brought forward, have been left in limbo. NHS England and local systems are now exploring workarounds, such as temporarily using mobile imaging units while the CDCs are established in attempt to win Mr Barclay’s backing. Cancer Research UK director of evidence and implementation Naser Turabi said: “Community diagnostic centres can help the NHS diagnose cancers more quickly, but they require capital investment and funding for staff if they are to meet rising demand. “Restricting the promised expansion of these centres will only lead to longer waits and worse outcomes for cancer patients in England.” Read full story (paywalled) Source: HSJ, 9 May 2023
  21. News Article
    A leading consultant has warned that poor care is at the root of a growing outcry over an invasive medical test that has left women in agony. Dr Helgi Johannsson, vice-president of the Royal College of Anaesthetists, has spoken out about the hysteroscopy after the Sunday Mail revealed the suffering of a series of female patients. His intervention comes amid a growing backlash around the procedure used to investigate and treat problems in the womb, with more than 3000 women now reporting being left with post-traumatic stress and excruciating pain. The test involves a long scope being inserted into the womb, often without anaesthetic, leaving one in three in pain. Dr Johannsson, a consultant anaesthetist at Charing Cross Hospital in London, said: “It sounds like a lot of this is poor care and badly handled, and emotionally badly handled, and (they) didn’t stop when they were supposed to. “Stories of being held down to finish the procedure are just awful. It’s important that we make the OH as good as we can possibly make it, including some sort of inhalation sedation, but having the ability to say stop when you need to is so important and a measure of good care.” Read full story Source: Daily Record, 7 May 2023 Further reading on the hub: Women share their experiences of painful hysteroscopy in the hub community. My experience of an outpatient hysteroscopy procedure Hysteroscopy: 6 calls for action to prevent avoidable harm
  22. Content Article
    Primary care, like many parts of the NHS and health systems globally, is under tremendous pressure – one in five people report they did not get through or get a reply when they last attempted to contact their practice. The Fuller Stocktake built a broad consensus on the vision for integrating primary care with three essential elements: streamlining access to care and advice; providing more proactive, personalised care from a multidisciplinary team of professionals; and helping people stay well for longer.  The joint NHS and Department for Health and Social Care (DHSC) plan is an important first step in delivering the vision set out in Dr Claire Fuller’s Next steps for integrating primary care.
  23. News Article
    Patients are developing cancers and enduring so much pain that they cannot climb stairs because of the 7.2 million-strong waiting list for NHS scans and treatment, Britain’s top GP has said. Prof Kamila Hawthorne, the chair of the Royal College of GPs, said the record delays for care and the uncertainty for patients about when they would finally be seen was leaving people feeling “helpless and forgotten”. These included people with heart problems, those awaiting a hip or knee replacement, and people with potential signs of cancer whom GPs have said need to be seen urgently, she said. In an interview with the Guardian, she voiced serious concern that some of these patients saw their health deteriorate as a direct result of the delay in accessing hospital care. “Patients getting sicker while they are on the waiting list is something GPs see and worry about, because the risk to the patient is so much greater. It’s inevitable that some people stuck will get sicker, because that’s the nature of illness,” she said. Read full story Source: The Guardian, 7 May 2023
  24. News Article
    Managers at a medical rehabilitation unit are "covering it up" when issues are raised, a whistleblower has said. The whistleblower claimed Cambridge Rehabilitation Unit (CRU) management bullied staff who flagged concerns over shortages and unsafe practice. Documents detail claims of "dangerous" staffing levels, patients left in bed all day without therapy and a one-star food hygiene rating. Through the Freedom of Information Act, the BBC discovered three whistleblowing complaints were made to the Care Quality Commission (CQC) between May and August last year. The first said wards "run on dangerous levels of staff" and no action was taken when staff flagged concerns. The second stated there was "bullying occurring from management when staff raise concerns regarding short staffing and unsafe practice". They said: "When issues relating to patient safety are raised... management are 'covering it up'." Read full story Source: BBC News, 9 May 2023
  25. News Article
    Millions of patients in England will be able to get prescriptions for seven common conditions, plus more blood pressure checks and the contraceptive pill, directly from pharmacies under proposals to tackle the crisis in GP surgeries. Those suffering from earache, a sore throat, sinusitis, impetigo, shingles, infected insect bites and uncomplicated urinary tract infections (UTIs) in women are set to be prescribed medicine by pharmacists without the need to see a doctor or nurse for the first time. The reforms are designed to free up 15m GP appointments over the next two years. The blueprint was broadly welcomed by health leaders, with Thorrun Govind, chair of the Royal Pharmaceutical Society in England, calling it a “real game-changer” for patients. But experts said not all pharmacies would be able to offer all or any of the new services, meaning the shake-up could result in frustrated patients being “bumped from pillar to post, only to end up back at the GP”. There are also concerns that patients may not be able to recognise the seriousness of some conditions, including whether a UTI can be classed as “uncomplicated”. Read full story Source: The Guardian, 9 May 2023
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