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Patient Safety Learning

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  1. Event
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    Care Opinion are hosting this interactive half-day online event. The event will be spilt into two key parts: Part 1. What have we learned from existing Care Opinion research? Part 2. What might we do in the future? Shaping the future of Care Opinion research and development. The event is a celebration of the work that has been completed within the NIHR Yorkshire and Humber Patient Safety Centre (PSTRC), and an opportunity to consider future ways to work with Care Opinion (www.careopinion.org.uk) within the new Patient Safety Research Collaboration (PSRC) and beyond. The event is open to anyone interested in learning more about Care Opinion and it’s potential for making care safer in three key ways: Care Opinion as a data resource. Care Opinion as a way to involve people in research. Care Opinion as an intervention for better care. Register
  2. News Article
    The rising prevalence of hernia disorders, technological advancements in hernia repair devices, growing adoption of mesh in hernia repair surgeries, rising geriatric population and high adoption of hernia repair surgical procedures are some of the key factors driving the global hernia repair devices market, reports Yahoo News. Leading players operating in the global hernia repair devices market are adopting both organic and inorganic growth strategies such as collaborations, acquisitions, and new product launches to garner a higher market share. For instance: In February 2023, TELA Bio, Inc announced the launch of two additional configurations of its OviTex LPR device. The new configurations are 15 x 20 cm and 15 x 25 cm ellipses designed for ventral and incisional hernias. In December 2022, Deep Blue Medical Advances announced that they have received an additional 510(k) clearance from the US FDA for its T-Line Hernia Mesh for the subway technique in open hernia surgery. However, in a recent Tweet, campaign group Sling the Mesh voice their concerns:
  3. News Article
    Charlotte Nolan, 23, has been fighting the deadly eating disorder anorexia for seven years. And in November she hit rock bottom. The student nurse was having weekly therapy sessions, but they weren’t helping and promised additional weekly visits from a support worker failed to materialise. Her food obsessions were spiralling out of control and her mental health was plummeting. Hopes were pinned on a meeting with her community mental health team, where it would be decided what to do next. There were discussions about several different treatment options. But the ultimate decision they made was baffling. Instead of continuing therapy, trying another treatment or hospital admission, they simply discharged her from care. She says: ‘I was sobbing, trying to express to a room full of strangers that I wasn’t sure I could cope, I wasn’t sure I could stay safe. Charlotte’s story is heartbreaking but, alarmingly, she is not alone. In fact, there are a rising number of desperately ill anorexia patients being deemed too sick to treat. Experts have voiced concerns about both NHS and private clinics withdrawing life-saving treatment. "I’ve been contacted by people who say they are discharged because they’re too sick or not recovering fast enough, and being told there’s nothing more that can be done,’ says Hope Virgo, an eating disorder campaigner and former patient. "It’s heartbreaking. Some have been referred to palliative care. We don’t give up on patients with physical illnesses, we find different treatment methods which work for them. And yet, with eating disorders, it’s still a case of one-size-fits-all. Why aren’t we setting people up to have a chance of recovery? Instead, if treatment doesn’t work, services are washing their hands of them." Read full story Source: Mail Online, 29 May 2023 Read a blog Hope Virgo wrote for the hub last year: People with eating disorders should not face stigma in the health system and barriers to accessing support in 2022
  4. News Article
    The US Food and Drug Administration has approved a vaccine against respiratory syncytial virus (RSV) - an illness that kills thousands of Americans each year. The vaccine still needs approval from the US Centers for Disease Control and Prevention before it can be rolled out to the public. Officials say the vaccine, named Arexvy by the manufacturer GSK, is a major breakthrough that will save many lives. It could be available to people over 60 within months, officials say. "Today's approval of the first RSV vaccine is an important public health achievement to prevent a disease which can be life-threatening," said Dr Peter Marks, who leads the Center for Biologics Evaluation and Research at the Food and Drug Administration (FDA). RSV is a respiratory illness that typically results in cold-like symptoms for adults, but can be dangerous for young children, the elderly, and those with underlying health conditions. Read full story Source: BBC News, 4 May 2023
  5. News Article
    Two years ago, administrators and caregivers at St. Bernard Hospital in Chicago were stunned when they flunked a basic standard for patient safety. "It was a real jolt," said Charles Holland, the hospital's president and CEO. "We thought we were doing patient safety and we thought we were doing it well." But the Leapfrog Group, a nonprofit health care watchdog organisation, found the hospital fell short on documenting and having comprehensive approaches to hand-washing, medication safety systems and fall and infection prevention. The wake-up call led Holland to hire a Patient Safety and Quality Officer and to use Leapfrog's criteria as a roadmap for improving patient safety. It worked. In its latest annual review of hospital safety, released Wednesday, Leapfrog awarded the century-old charity hospital an A. The fact that St. Bernard could turn around so quickly and so effectively without spending a fortune in the process shows that patient safety is an attainable goal, said Leah Binder, Leapfrog's president and CEO. Read full story Source: USA Today, 3 May 2023
  6. Event
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    In the context of the complex challenges across the health and care landscape, including significant workforce shortages and limited clinical capacity, this free online event will consider the role of diagnostics in supporting those working in the system and keeping people out of hospital. The King's Fund event will explore: the potential that increased access to diagnostic testing, and in particular in vitro diagnostic testing, in primary care, the community and in community diagnostic hubs offers to diagnosing people earlier and avoiding unnecessary hospital admissions what innovations in patient pathways mean for those working across the system and how they are being supported to make changes, in the context of the significant challenges they are facing the role integrated care systems can play in developing diagnostic services that encourage innovation and are designed with people and communities at their heart. Register
  7. News Article
    The Nursing and Midwifery Council (NMC) has withdrawn its accreditation of the midwifery programme at a Kent university due to fears over quality and safety. The regulator highlighted concerns that Canterbury Christ Church University students were not gaining the expertise needed to deliver safe, effective and kind care. An NMC director said the decision was made in the “best interests of women, babies, and families”. The university said the decision had “devastating consequences” for their student midwives. “Our absolute priority is the wellbeing of our students and staff, and ensuring that our students can continue to complete their studies and begin their future careers, to be the high quality, much needed midwives that this region needs,” a university spokesperson said. Sam Foster, NMC executive director of professional practice, said while the decision would impact students and the local workforce, the regulator's role was to uphold the high standards that “women and families have the right to expect”. Read full story Source: BBC News, 4 May 2023
  8. News Article
    Wales' response to the pandemic could be investigated by a new Senedd committee under a deal between Welsh Labour and the Welsh Conservatives. A special committee will see if there are any gaps in what the UK Covid-19 inquiry says about Wales. It follows a long-running row over whether Wales needs its own probe into the pandemic. The Welsh Conservatives welcomed the "halfway-house" compromise. The Welsh government has continued to resist calls for a Wales-specific public inquiry into Covid, supporting instead the UK-wide effort chaired by Baroness Hallett. The inquiry has a sub-module specific to Wales and will hold public hearings in the country this autumn. Campaigners fear the UK inquiry will not be comprehensive enough. Read full story Source: BBC News, 4 May 2023
  9. News Article
    The NHS must start sharing figures on mental health checks for pregnant women and new mothers amid gaps in hospital data, top doctors warn. One in six NHS trusts is not able to say whether they screen pregnant women for mental health issues at all, despite national guidelines recommending these checks be done at 10 weeks. Suicide has been recorded has one of the leading drivers in post-natal deaths. The findings come as the latest NHS figures show 51,000 women accessed specialist perinatal mental health services in the 12 months prior this fell short of a target for the NHS to see 66,000 mothers in 2022-23. Access levels have. however, improved from 31,000 a year in March 2022. The Royal College of Psychiatrists has called for NHS England to “urgently” publish data on every hospital in the country showing whether they are carrying out this vital screening. Last November the latest national report into maternal deaths, from researchers led by Oxford University, found suicide was again the leading cause of direct deaths in women a year after the end of their pregnancy. Read full story Source: The Independent, 4 May 2023
  10. News Article
    The national patient safety commissioner has hit out at government for failing to confirm her budget a month into the financial year, warning that she is ‘incredibly limited’ in what she can achieve. In an strongly worded letter released today, Henrietta Hughes states: “Despite it now being the end of April the Department has still not provided me with a budget for this financial year.” She added: “This ambiguity and delay is impacting on my ability to arrange patient engagement events as these require a budget”. It appears to be an almost unprecedented public intervention from an official who is appointed and hosted by the DHSC. In the letter to Commons Health and Social Care Committee chair Steve Brine, she also says she does not have enough resources to fulfil the role, and is only able to employ four members of staff. Read full story (paywalled) Source: HSJ, 3 May 2023
  11. News Article
    The world is “on the cusp of a first generation of treatments for Alzheimer’s disease”, experts have said, as a new drug was found to slow cognitive and functional decline. The drug donanemab, made by Eli Lilly and Company, slowed decline by 35% to 36% in a late-stage phase 3 clinical trial, the company said. Donanemab appeared to slow the decline associated with Alzheimer’s compared to placebo in 1,182 people with early-stage disease based on those with intermediate levels of a protein known as tau. The drug also resulted in 40% less decline in the ability to perform activities of daily living, according to the firm. Dr Susan Kolhaas, executive director of research and partnerships at Alzheimer’s Research UK, said: “This is incredibly encouraging, and another hugely significant moment for dementia research". “The treatment effect is modest, as is the case for many first-generation drugs, and there are risks of serious side effects that need to be fully scrutinised before donanemab can be marketed and used. “However, this news underlines the urgency of preparing the NHS to make these treatments available should regulators deem them safe and effective". Read full story Source: The Independent, 3 May 2023
  12. News Article
    Thousands of NHS-funded talking therapy sessions are still being carried out by unaccredited practitioners every month, despite NHS England trying to stop the practice for at least five years. NHS Digital data for January this year showed 44,170 sessions involved practitioners who were neither in training nor had done an accredited course. The actual figure could be higher as, of the 517,027 sessions in total carried out, data about who was involved was missing for more than half (328,433). Since last June, practitioners delivering NHS-funded “low intensity” talking therapies – previously known as Improving Access to Psychological Therapies – are required to be part of either the British Psychological Society or the British Association for Cognitive and Behavioural Psychotherapies’ registers. The registers, which were set up in 2021, confirm practitioners have completed an accredited course, ensure continuous professional development and provide a framework for striking off. Meanwhile, NHSE’s IAPT manual – first published in 2018 – states all clinicians should have completed an accredited training programme and a “robust and urgent” plan should be in place to train those who have not, including the possibility of those without accreditation being prevented from working alone. Read full story (paywalled) Source: HSJ, 3 May 2023
  13. News Article
    The UK needs at least 11,000 more school nurses to deal with the increasingly complex needs of young people after the pandemic, and help prevent them from developing serious mental health problems, researchers and campaigners say. The number of school nurses has fallen by 35% in the last five years to about 2,000, and research by Oxford Brookes University, the University of Birmingham and the Oxford Health NHS foundation trust has found that a lack of long-term investment has resulted in many local areas scrapping the roles altogether. The researchers surveyed 78 school nurses who shared feelings of exhaustion, stress and low morale, said Dr Georgia Cook, a researcher at Oxford Brookes University. “Policymakers need to recognise and promote the integral role of school nurses in carrying out preventive public health work,” Cook said. “This should be supported by a sufficient workforce though, and bolstering school nurse numbers will be key to meeting the increasingly complex needs of children and young people in the wake of the pandemic.” Read full story Source: The Guardian, 2 May 2023
  14. News Article
    A "dire" lack of dentists has led to people "self-medicating every night", an MP has said. Barrow and Furness MP Simon Fell said his constituents included seven-year-olds who had never seen a dentist and pregnant women who could not get an appointment. “That simply is not good enough," he said. "I now have constituents who have not seen a dentist in years," he said. “There are pregnant mothers who are unable to make their appointments, constituents who are self-medicating every night because they cannot find care, seven-year-olds who have never seen a dentist and constituents performing their own dental care with packs they buy from Boots the Chemist." Mr Fell told Parliament dental practices had told him they were unable to recruit enough dentists, especially in "rural, isolated areas such as mine". He had been told the process for bringing in dentists from overseas "does not meet demand" and the administration for recording patient care, and the resulting payment to dentists, was "long-winded and overly complex", he said. Read full story Source: BBC News, 3 May 2023
  15. Content Article
    The Learn from Patient Safety Events (LFPSE) service is a new national NHS service for the recording and analysis of patient safety events that occur in healthcare, supporting the NHS to improve learning from the 2.5 million+ patient safety events recorded each year. All healthcare staff are encouraged to record patient safety events to support national and local improvement to make care safer for patients. This short video from NHS England introduces LFPSE.
  16. News Article
    Women’s lives are being put at risk by substandard mental health care during their pregnancy and in the first year after childbirth in most parts of the UK, a report has found. About one in every five women develops a mental illness at some point during the perinatal period, the stage from pregnancy up to a year after giving birth. However, none of the health and social care boards in Northern Ireland or Wales met the national quality standards created by the Royal College of Psychiatrists’ Perinatal Quality Network (PQN). Maternal deaths due to mental health problems are also increasing, with maternal suicide being the lead cause of deaths in the first year after childbirth. Despite this, the report by the Maternal Mental Health Alliance (MMHA) found that many specialist perinatal mental health services do not receive adequate attention or investment, or meet the quality standard of care. The minimum standard of care that women, babies and families should receive is defined as PQN standards type 1. In England, only 16% of the specialist perinatal mental health community teams met these standards. Read full story Source: The Guardian, 2 May 2023
  17. News Article
    Fresh concerns have been raised about the launch of the national incident reporting system, despite Steve Barclay taking a ‘personal interest’ in hitting the tight timetable, HSJ has learned. NHS England already delayed the launch of the “learning from patient safety events” database by six months, to September this year. It is due to replace the existing national reporting and learning system (NRLS) which is considered to be outdated and at risk of failing. But serious concerns are now being raised again by trust safety managers about whether the revised launch date can be met, HSJ has been told, with calls for it to be extended again until next year. HSJ has heard concerns from several managers that an upgrade due in July to the RLDatix risk management system – which is used by the majority of trusts – will cause knock-on problems implementing LFPSE in September. They said the timeframe was too short for testing and delivering the upgrade in time to make the transition and decommission the old NRLS. The creation of LFPSE is a key part of NHSE’s safety strategy, along with replacing the serious incident reporting system, with an aim of making it easier for staff to record safety events across all services, including primary care, which is excluded from NRLS. Read full story (paywalled) Source: HSJ, 3 May 2023
  18. News Article
    Maternity services at a trust in Staffordshire have been rated as 'requires significant improvement' by the Care Quality Commission (CQC). University Hospitals of North Midlands NHS Trust in Stoke-on-Trent must now make urgent changes by June 30th 2023, to ensure patients are cared for safely. It follows an inspection in March where inspectors said staff did not have enough effective systems in place to ensure patients were looked after to the standard they should be. Staff also failed to implement a prioritisation process to ensure delays in the induction of labour were monitored and effectively managed, according to the review of services. The CQC said midwives evaluating patients and handling triage processes did not effectively assess, document and respond to the ongoing risks associated with safety through triage. Read full story Source: ITV News, 28 April 2023
  19. Content Article
    The Dutch Hospital Patient Safety Program started in 2008. It initially ran for five years, and its aim was to decrease adverse events by 50% in all Dutch hospitals. A second National Safety Program launched in 2020. This focuses on reflection, interprofessional collaboration and explaining process variation in daily practice. It also looks to foster more patient involvement and shared decision making. The ultimate aim is to reach a significant reduction in preventable patient harm. This webinar provides an overview of patient safety in the Netherlands and discusses these two initiatives and their implementation, outcomes and ongoing impact.
  20. News Article
    Health unions representing the majority of NHS workers have voted to accept the government’s pay deal after months of strikes. In a joint statement, members of the NHS Staff Council said the unions agreed to the deal for staff on the Agenda for Change contract, which includes all NHS workers apart from doctors, dentists and senior managers. Unison and GMB unions - as well as smaller unions representing midwives and physiotherapists - voted to accept the deal, while the Royal College of Nursing voted against it. However, those in favour of the deal had the majority. This bank holiday weekend saw the most extreme strikes yet from nurses with no exceptions for A&E, critical care and and cancer agreed nationally Read full story Source: The Independent, 2 May 2023
  21. News Article
    US federal health officials say two hospitals broke the law by denying an abortion to a woman experiencing a life-threatening emergency. The hospitals, in Kansas and Missouri, are now being probed by the Department of Health and Human Services (HHS). The investigation is the first of its kind to be launched since the Supreme Court invalidated the national right to an abortion last year. After the Supreme Court ruling, the White House warned hospitals that doctors must provide abortions if the health of the patient is at risk - even in states that have banned abortion. "Fortunately, this patient survived. But she never should have gone through the terrifying ordeal she experienced in the first place," HHS Secretary Xavier Becerra said in a statement seen by BBC News. "We want her, and every patient out there like her, to know that we will do everything we can to protect their lives and health, and to investigate and enforce the law to the fullest extent of our legal authority, in accordance with orders from the courts." Read full story Source: BBC News, 1 May 2023
  22. News Article
    Recreational vaping will be banned in Australia, as part of a major crackdown amid what experts say is an "epidemic". Minimum quality standards will also be introduced, and the sale of vapes restricted to pharmacies. Nicotine vapes already require a prescription in Australia, but the industry is poorly regulated and a black market is thriving. Health Minister Mark Butler says the products are creating a new generation of nicotine addicts in Australia. Also known as e-cigarettes, vapes heat a liquid - usually containing nicotine - turning it into a vapour that users inhale. They are widely seen as a product to help smokers quit. But in Australia, vapes have exploded in popularity as a recreational product, particularly among young people in cities. Vapes are considered safer than normal cigarettes because they do not contain harmful tobacco - the UK government is even handing them to some smokers for free in its "swap to stop" programme.But health experts advise that vapes are not risk-free - they can often contain chemicals - and the long-term implications of using them are not yet clear.Read full story Source: BBC News, 2 May 2023
  23. News Article
    The mother of a nine-year-old girl who died from hyponatraemia has said a new inquest that started today is "an opportunity for truth". Raychel Ferguson, from Londonderry, died at the Royal Belfast Hospital for Sick Children in June 2001. Her parents, Ray and Marie Ferguson, have long campaigned to find out the truth about their daughter's death. Hyponatraemia is an abnormally low level of sodium in blood and can occur when fluids are incorrectly administered. Mrs Ferguson said the fact there was a second inquest "speaks to the culture of cover up that has plagued her death, involving the medical and legal professions". An inquiry in 2018 into the deaths of five children in Northern Ireland hospitals, including Raychel, found her death was avoidable. The 14-year-long inquiry into hyponatraemia-related deaths was heavily critical of the "self-regulating and unmonitored" health service. In January 2022, a new inquest opened but was postponed in October after new evidence came to light. Read full story Source: BBC News, 2 May 2023
  24. News Article
    Doctors, scientists and researchers have built an artificial intelligence (AI) model that can accurately identify cancer in a development they say could speed up diagnosis of the disease and fast-track patients to treatment. Cancer is a leading cause of death worldwide. It results in about 10 million deaths annually, or nearly one in six deaths, according to the World Health Organization. In many cases, however, the disease can be cured if detected early and treated swiftly. The AI tool designed by experts at the Royal Marsden NHS foundation trust, the Institute of Cancer Research, London, and Imperial College London can identify whether abnormal growths found on CT scans are cancerous. The algorithm performs more efficiently and effectively than current methods, according to a study. The findings have been published in the Lancet’s eBioMedicine journal. “In the future, we hope it will improve early detection and potentially make cancer treatment more successful by highlighting high-risk patients and fast-tracking them to earlier intervention,” said Dr Benjamin Hunter, a clinical oncology registrar at the Royal Marsden and a clinical research fellow at Imperial. Read full story Source: The Guardian, 30 April 2023
  25. News Article
    Thousands of children in mental health crisis are being treated on inappropriate general wards – with some forced to stay for more than a year and staff not properly trained to care for them, shocking new data reveals. New figures uncovered by The Independent show at least 2,838 children needing mental health care were admitted to non-psychiatric hospitals last year as the NHS battled with a lack of specialist staff and a surge in patients. Children with eating disorders – who often need to be restrained to be fed through tubes – are among those being routinely put on general wards. It means staff without any specialist training, including security guards, are sometimes left to restrain these young patients. One trust chief nurse told The Independent that porters had to be trained to restrain children on paediatric wards, causing trauma for both patients and staff. Dr Camilla Kingdon, president of the Royal College of Paediatrics and Child Health, said she was “deeply concerned” about the situation. “We now find ourselves in a situation where children and young people who have an eating disorder or mental ill health, and who may be on long waiting lists for treatment, are increasingly ending up in emergency settings and then being treated on general paediatric wards. This simply isn’t good enough,” she said. Read full story Source: The Independent, 1 May 2023
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