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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Long-running supply issues with blood collection equipment risk delaying the elective recovery, according to an internal NHS Supply Chain communication seen by HSJ. Global supply and manufacturing delays have caused the delivery of blood collection sets, apparatus used to draw intravenous blood into vacuum tubes, by months. The problems are affecting multiple products and suppliers. An NHS Supply Chain procurement advisory cell communication warned trusts: “There is a risk that the continued supply disruption of blood collection sets is delaying elective recovery, with providers restricting blood collection to continue to prioritise urgent procedures.” This is the second “important customer notice” relating to supply problems with blood collection equipment issued by the national procurement agency. Read full story (paywalled) Source: HSJ, 9 May 2023
  2. News Article
    The World Health Organization (WHO) has declared that Covid-19 no longer represents a "global health emergency". The statement represents a major step towards ending the pandemic and comes three years after it first declared its highest level of alert over the virus. Officials said the virus' death rate had dropped from a peak of more than 100,000 people per week in January 2021 to just over 3,500 on 24 April. The head of the WHO said at least seven million people died in the pandemic. But Dr Tedros Adhanom Ghebreyesus said that the true figure was "likely" closer to 20 million deaths - nearly three times the official estimate - and he warned that the virus remained a significant threat. "Yesterday, the Emergency Committee met for the 15th time and recommended to me that I declare an end to the public health emergency of international concern. I've accepted that advice. It is therefore with great hope that I declare Covid-19 over as a global health emergency," Dr Tedros said. Read full story Source: BBC News, 6 May 2023
  3. Content Article
    Wound care is a critical aspect of healthcare that affects people of all ages. The National Wound Care Strategy Programme (NWCSP) is addressing the unwarranted variation in wound care services, not enough use of evidence-based practices and use of ineffective practices.   The NWCSP’s goal is to reduce pain and suffering for patients, improve healing rates, prevent wounds from happening or coming back, and use healthcare resources more efficiently. PRSB’s wound care standard will help to support this goal by encouraging use of evidences-based practice and consistent recording of information which can be shared with all those involved in the person’s care.  The standard defines the information record content for the management of wound care. It is designed to support the professionals and those providing care as well as the person themselves, and to support the national wound care strategy.
  4. News Article
    GPs in South London have eradicated a large gap in blood pressure control between white patients and those from a Black or minority ethnic background, after a year-long project. AT Medics Streatham PCN in Lambeth found that among their patients under 80 diagnosed with hypertension, there was a 12% inequality gap in blood pressure control, with 67% of white patients and 55% of black patients treated to target. The two practices in the PCN have 45,000 patients, with around 3,100 diagnosed with hypertension. They set up a centralised recall system and made use of practice pharmacists and healthcare assistants to provide guidance, education around self-care, lifestyle and medicines. Dr Tarek Radwan, GP director said: ‘This project has delivered incredible results, and this is all down to the dedication of our amazing team, especially our administrators, healthcare assistants and pharmacists. "The last 12 months have proved that we can not just reduce but actually eradicate health inequalities and raise the quality of care for everyone at the same time. "I know the difference this will make to our local communities, and it really shows what is possible with a highly motivated multidisciplinary team." Read full story Source: Pulse, 3 May 2023
  5. Content Article
    Helen Vernon explains why the role of director of safety and learning at NHS Resolution can make a lasting difference to the safety of NHS patients.
  6. Content Article
    Care home residents are particularly vulnerable to patient safety incidents, due to higher likelihood of frailty, multimorbidity and cognitive decline. However, despite residents and their carers wanting to be involved in safety initiatives, there are few mechanisms for them to contribute and make meaningful safety improvements to practice. This study aimed to develop a measure of contributory factors to safety incidents in care homes to be completed by residents and/or their unpaid carers.
  7. Content Article
     The discipline of ergonomics, or human factors engineering, has made substantial contributions to both the development of a science of safety, and to the improvement of safety in a wide variety of hazardous industries, including nuclear power, aviation, shipping, energy extraction and refining, military operations, and finance. It is notable that healthcare, which in most advanced societies is a substantial sector of the economy and has been associated with large volumes of potentially preventable morbidity and mortality, has not up to now been viewed as a safety critical industry. This paper from Robert L Wears proposes that improving safety performance in healthcare must involve a re-envisioning of healthcare itself as a safety-critical industry, but one with considerable differences from most engineered safety-critical systems. This has implications both for healthcare, and for conceptions of safety-critical industries. 
  8. Content Article
    The nature of patient needs and ward activity is changing. Inpatients tend to be more ill than they used to be, many with complex needs often arising from multiple long-term conditions. At the same time, hospitals face the challenges of a shortage and high turnover of registered nurses. This review presents recent evidence from National Institute for Health Research (NIHR)-funded research, including studies on the number of staff needed, the support workforce and the organisation of care on the wards. While few research studies have explored the similar pressures that occur in community and social care, the learning from hospitals may be useful to decision makers in these areas.
  9. News Article
    The Government’s “blanket erasure” of older people with learning disabilities is leaving a growing population unsupported and piling further pressure on family carers, new research will warn. Byline Times has seen early findings from a forthcoming national study which outlines the urgent need to avoid a crisis by creating a government strategy for this unacknowledged community. With around 1.5 million people with learning disabilities in the UK, Manchester Metropolitan University (MMU)’s ‘Growing Older Planning Ahead‘ research lays bare the Government’s short-sighted approach to learning disability support. The study estimates around 81,000 over-50s within this population in England alone, many of whom are not in contact with services. In addition, figures show that between 2012 and 2030 in England, the number of learning disabled people needing social care will have increased by almost 70% (from more than 140,000 to 235,000). Sara Ryan, MMU Professor of Social Care who led the three-year project, said: “Ageing opens up all sorts of different things, you turn down the dial on some things and up on others. If you’re lucky enough, you have a lot to look forward to – but for people with learning disabilities, there’s a blanket erasure of age.” Read full story Source: Byline Times, 3 May 2023
  10. Content Article
    The Primary Care Patient Measure of Safety (PC PMOS) is designed to capture patient feedback about the contributing factors to patient safety incidents in primary care. It required further reliability and validity testing to produce a robust tool intended to improve safety in practice. This study led to a reliable and valid 28-item PC PMOS that could enhance or complement current data collection methods used in primary care to identify and prevent error.
  11. Event
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    Learn from Dr Bill Kirkup and other key speakers about recent National Maternity Service Reviews and how they are changing practice. Register
  12. Content Article
    On 23–24 February 2023, the 5th Global Ministerial Summit on Patient Safety in Montreux, Switzerland, marked the first convening of global leaders to discuss patient safety for more than 3 years. The summit provided the opportunity to reimagine the way safe care is delivered using learnings from the COVID-19 pandemic. In this correspondence in the Lancet, Shaw et al. hopes we will look back at the Montreux summit as a turning point in patient safety: the catalyst for moving from plans to actions, so that at future summits we can discuss shared learning and evaluation of health systems that deliver safe care to all.
  13. News Article
    The Royal College of Surgeons of England is conducting a census to gain a better understanding of the surgical workforce. Through the census, they will be able to gather comprehensive information on the composition of the surgical workforce, its demographics and working practices. Most importantly, it allows members of the surgical workforce to share the most pressing challenges they are facing. It aims to: Better appreciate the needs, challenges, and working practices of the surgical workforce. More effectively represent and advocate for the workforce. Offer better support Create a better working environment. Enhance sustainability, including measures to improve retention, recruitment and work-life balance. Improve future planning. Take part in the survey
  14. News Article
    Only one NHS trust in England provides dedicated training to prevent sexual harassment, according to research, raising concerns that the NHS is failing to adequately protect staff and patients. According to health union figures, sexual harassment of staff is pervasive. A 2019 survey by Unison found that one in 12 NHS staff had experienced sexual harassment at work during the past year, with more than half saying the perpetrator was a co-worker. In a recent BMA survey, 91% of female doctors reported sexism, 31% had experienced unwanted physical contact and 56% unwanted verbal comments. Yet research by the University of Cambridge, published in the Journal of the Royal Society of Medicine found that the vast majority of NHS trusts did not provide any dedicated training to prevent sexual harassment. The report analysed data from freedom of information requests from 199 trusts in England and found that just 35 offered their workers any sort of active bystander training (ABT), while only one NHS trust had a specific module on sexual harassment. ABT is designed to give individuals the skills to call out unacceptable behaviour, from workplace bullying to racism and sexual misconduct. It is widely used by the military, universities and Whitehall, including the Home Office. Read full story Source: The Guardian, 5 May 2023
  15. Event
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    While scientific breakthroughs are giving people with breast cancer more hopeful outcomes, much improvement is needed in cancer diagnosis and treatment rates, which have seen further setbacks as a result of the disruption caused by the COVID-19 pandemic. The COVID-19 legacy has also transformed many practices in cancer care and research settings. So, what does this mean for nurses working in breast cancer today? This timely and up-to-the-minute webinar offers you a chance to benefit from the latest research and guidance on breast cancer care, from screening through to treatment. With a firm focus on the role of the nurse, this event will create a supportive environment in which you can hear from experts, ask your questions and engage with a community of breast cancer nurses facing the same daily challenges as you. Register
  16. Content Article
    The results from the 2022 British Social Attitudes survey made for very difficult reading for those of us working in the NHS right now. Overall satisfaction with the NHS is at the lowest level ever recorded and similarly satisfaction with individual services is at record lows across the board, but it was satisfaction with A&E services that saw the sharpest fall in 2022.  Kelly Ameneshoa, an Emergency Medicine Doctor working across South London and Surrey, reflects on the findings.
  17. Event
    It is now clear that hormone pregnancy test Primodos, the epilepsy drug sodium valproate, and that pelvic mesh causes avoidable harm to many thousands of women and children. Yet recognising these potential harms took many years, and it is still the case that the service does not know the identities of all those affected or potentially affected. The main reason is lack of data. Knowing which patients have received which medicines and devices where, and quickly connecting longer-term outcomes, has traditionally been somewhere between impossible and extremely slow and difficult. Unnecessary harm has often been the result. So how can the NHS solve this issue? What do we know about the traditional challenges with traceability in healthcare and the shortcomings of current data collection techniques? How can it be ensured that the right products are being used for the right patient? What approaches and technologies might solve these challenges, ensuring that the right products are being used for the right patient? How could this fit into wider digital transformation work, and resulting data best be used to improve patient safety and outcomes? This HSJ webinar, run in association with GS1 UK, will bring together a small panel to consider the answers to these important questions. Register
  18. News Article
    A former top medic on the Isle of Man who was unfairly dismissed has said her career has been "shattered" by her treatment. Rosalind Ranson was the Department of Health and Social Care's (DHSC) medical director from January 2020. She was awarded a record £3.19m in compensation after a lengthy tribunal which ruled she had been unfairly dismissed for whistleblowing. Dr Ranson raised a number of serious concerns about the coronavirus advice on the island that was not being passed on to ministers. She was later marginalised before being dismissed as the island's top medic when the operational services of DHSC transitioned into Manx Care. Dr Ranson said: "For me it is a tragedy that my 35-year career in medicine has come to an end through these circumstances. "I was proud of my professional integrity, my resilience, and my strength to stand up for those that I protected through my work as a doctor." Read full story Source: BBC News, 4 May 2023
  19. News Article
    A host of algorithms used by medics to assess disease risk and help make decisions on treatment are failing to take transgender patients into account, doctors have said. Many metrics and thresholds in medicine, including ideal body weight, alcohol clearance rates, kidney function and risk of cardiovascular disease vary by gender. A team of UK doctors and medical students have issued a warning over a lack of evidence as to whether trans patients should be considered for these gender-based scores according to their gender assigned at birth or the gender they have transitioned to – or whether alternative scores are required. In an effort to tackle the issue, the team have launched a research initiative called Trans Gap Project. Dr Michael Niman, a junior NHS doctor and chair of the project, said: “Currently, daily medical decisions involving gender-based scores have limited to no research for the trans community. This means that trans patients are often forgotten about or not considered in the medical world, leading to a significant gap in their access to appropriate medical care.” “When scores that haven’t considered trans people are used, patient autonomy is impaired for trans and gender-diverse patients, as they can’t make true informed decisions on their care – which is one of the bioethic pillars,” Niman said. In some cases, there could be safety concerns. “Clinicians are currently faced with uncertainty regarding the best clinical practice to address these scenarios, owing to a lack of evidence-based guidance,” Niman said. “It is vital clinicians take a vested interest in the research of gender-based scores for the trans community due to the importance of safe practice considerations within the NHS.” Read full story Source: The Guardian, 5 May 2023
  20. News Article
    Distress and heartbreak for millions could have been avoided if the government had not missed opportunities to prepare social care for a pandemic, according to a big investigation into how the first wave of Covid hit care homes. A review of events in spring 2020, when almost 20,000 care home residents died with Covid in England and Wales, found it was the result of “letting one of our most important public services languish in constant crisis for years”. A two-year study by the Nuffield Trust health thinktank and the London School of Economics found successive governments failed to respond to risks already exposed by cross-government pandemic planning exercises, didn’t have enough civil servants working on social care, and failed to appreciate the sector’s fragility when sending patients into ill-prepared care homes. The study is the latest independent assessment to undermine the claim by the former health secretary, Matt Hancock, to have thrown “a protective ring around social care”. It comes before the Covid-19 public inquiry’s investigation into the care sector, the timing of which has yet to be announced. Read full story Source: The Guardian, 5 May 2023
  21. Content Article
    Social care in England entered the pandemic in a fragile state. With much already written about the government’s response to the Covid-19 pandemic in the social care sector, this new report from the Nuffield Trust in collaboration with the Care Policy and Evaluation Centre analyses the structural and systemic factors that influenced that initial national response. Covid had far-reaching impacts on social care and exacerbated many longstanding issues. This work seeks to highlight progress and identify where action is needed to create a more resilient system.
  22. News Article
    A patient who was left scarred for life when a botched operation left him with horrific burns has received a payout after suing the NHS. Paul Hickman, 44, underwent routine surgery to improve circulation in his legs when medics at Russell Hall Hospital in Dudley, West Midlands, wrongly used a heated mattress. He ended up with significant burns on his buttocks after an alcohol-based solution came into contact with the back of both thighs and his backside. Mr Hickman, of Walsall, West Midlands, said: “I hoped that the surgery would go well and would improve my health. “However, all I remember afterwards was being in severe pain. “To be told I had suffered burns was a complete shock and at first was difficult to try and take in. I couldn’t understand how that had happened". An NHS investigation found the use of heated mattresses was stopped in the type of procedure Mr Hickman underwent after another patient was burnt in 2016. The report found the use of alcohol-based solution during Mr Hickman’s preparation for surgery and the “inappropriate use” of a heated mattress in surgery led to his burns. Read full story Source: The Independent, 4 May 2023
  23. News Article
    A "very concerning" rise in the number of people catching measles in the UK has been reported by health officials. There were 54 cases of measles in the whole of last year. However, there have already been 49 in the first four months of 2023. The UK Health Security Agency (UKHSA) is encouraging parents to ensure their children's vaccinations are up to date. The main symptoms of measles are a fever and a rash. But it can cause more serious complications including meningitis, and an infection can be fatal. Vaccination rates had been falling in the UK before the Covid pandemic. However, the disruption caused by Covid has dented vaccination programmes around the world, including in the UK, meaning even more children have missed out. The World Health Organization has already warned of a "perfect storm" for measles, because the fewer people who receive protection from vaccines, the easier it is for outbreaks to happen. Read full story Source: BBC News, 4 May 2023
  24. News Article
    A national Long Covid and Covid-19 database is among the key recommendations of a unanimous report released by an Australian parliamentary Committee for its inquiry into Long Covid and repeated Covid infections. The House of Representative’s Standing Committee on Health, Aged Care and Sport’s report aims to improve Australia’s response to Long Covid, an often-debilitating condition possibly affecting hundreds of thousands of Australians. The Chair of the Committee, Dr Mike Freelander MP said: ‘It is clear that the emergence of Long Covid has created challenges for patients and health care professionals alike. People with Long Covid suffer from a lack of information and treatment options. Health care professionals, who worked tirelessly over the acute phase of the pandemic, are now in a difficult situation trying to support patients with this new and poorly understood condition.’ The Committee made nine unanimous recommendations aimed at strengthening the Australian Government’s management of Long Covid, including regarding: A definition of long COVID for use in Australia Evidence-based living guidelines for long COVID, co-designed with patients with lived experience A nationally coordinated research program for long COVID and COVID-19 The COVID-19 vaccination communication strategy Access to antiviral treatments for COVID-19 Support for primary healthcare providers Indoor air quality and ventilation. Read full story Source: Parliament of Australia, 24 April 2023
  25. Event
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    The Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. Transition webinars focus on the different phases of the PSIRF preparation guide and feature presentations from NHS organisations currently transitioning to PSIRF. Transition webinars are open to everyone to attend, including both NHS and arms length bodies Presenters: Nicky Ore – Deputy Director of Patient Safety, Mersey Care NHS Foundation Trust Jo Rowan – PSIRF Project Manager, Mersey Care NHS Foundation Trust Kim Bennett – PSIRF Clinical Project Manager, Mersey Care NHS Foundation Trust Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Lauren Mosley, Head of Patient Safety Implementation, NHS England Register
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