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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    The watchdog responsible for investigating unresolved healthcare complaints has been warned repeatedly for nine months about problems with Sciensus, a private company paid millions to deliver vital medicines to NHS patients, the Guardian can reveal. The Parliamentary and Health Service Ombudsman (PHSO) has received 18 official requests to examine grievances against Sciensus since August last year, but has not begun any investigations, according to a person familiar with the matter. The revelation comes after a Guardian investigation exposed serious and significant concerns raised by patients, clinicians and health groups about Sciensus. The investigation revealed that the company has struggled to provide a safe or reliable service. Patients persistently complain about delayed or missed home deliveries of medication, the Guardian found, with clinicians warning that the health of some has deteriorated as a result. The investigation also uncovered how some NHS staff experience “daily issues” with Sciensus. Others reported an increase in patients “flaring” as a result of missed or delayed medication. Some have seen a rise in hospital admissions. In the wake of the investigation, the Care Quality Commission, the care regulator, said it was “aware of concerns raised” about Sciensus, and was reviewing them. Read full story Source: The Guardian, 1 May 2023
  2. News Article
    Women are dying or suffering avoidable harm because of a failure to recognise ectopic pregnancy, one of the country’s leading experts on maternal health has said. Speaking to the Guardian, Prof Marian Knight of the University of Oxford, who leads a national research programme on maternal deaths, called for action to improve diagnosis of the acute, life-threatening condition, in which a fertilised egg implants itself outside the womb, normally in the fallopian tube. Ectopic pregnancies are never viable and if left untreated can result in the tube rupturing, causing potentially fatal internal bleeding. “We could prevent more women from dying from ectopic pregnancy because of lacking of basic recognition and management of the condition,” said Knight. The warning comes as new data obtained by freedom of information request suggests that dozens of women have experienced “severe harm” after being admitted to hospital with ectopic pregnancies in the past five years. The Mbrrace report, published last year, said eight women died from ectopic pregnancies between 2018 and 2020, all but one of whom had received suboptimal treatment. In three instances, better care might have saved their lives, the report concluded. “There’s no doubt that in the [maternal deaths] inquiry we are still seeing the same messages of ectopic pregnancy not being recognised,” said Knight. “That people either don’t pick up on the fact that they’re pregnant or get single-minded about one diagnosis.” Read full story Source: The Guardian, 1 May 2023
  3. Content Article
    Central line–associated bloodstream infections (CLABSI) account for many harms suffered in healthcare and are associated with increased costs and disease burden. Central line rounds, like medical rounds, are a multidisciplinary bedside assessment strategy for all active central lines on a unit. The project team designed a HIPAA-protected, text-based process for assessing central lines for risk factors contributing to infection. Staff initiated a consultation via a virtual platform with an interdisciplinary team composed of oncology and infectious disease experts. The virtual discussion included recommendations for a line-related plan of care.
  4. Content Article
    Physicians raised a concern to the Quality Department about patients who were diagnosed in the emergency department (ED) with a urinary tract infection (UTI) but who later were clinically reviewed and found to be without disease. These patients were often admitted and treated with potentially unnecessary antibiotics.
  5. Content Article
    In this blog, Patient Safety Learning considers key patient safety issues relating to complications from surgical mesh implants, highlighting further sources of opinion and research on the hub.
  6. Content Article
    Read the latest monthly letters from the Chairman of the Patient Safety Movement Foundation.
  7. Content Article
    Whether beginning a new effort or trying to keep people motivated to better prepare for future hazards, applying risk communication principles will lead to more effective results. This self-guided module introduces seven best practices, numerous techniques, and examples to help you improve your communication efforts. Please note that this training focuses on improving risk communication skills for coastal hazards planning and preparedness, however the principles can be adapted for any setting, including healthcare.
  8. Content Article
    Appreciative Inquiry (AI) initiatives are implemented using the '4-D cycle' (Discovery, Dream, Design and Destiny). It's a methodology that allows an organisation to identify its positive core strengths relative to the 'affirmative topic' being addressed and and initiate concrete operational steps to achieve its goals. This article explains more.
  9. Content Article
    A gap analysis identified the need for process improvement surrounding the identification and reporting of adverse drug reactions related to moderate sedation. A change to documentation was selected to address this gap. The challenge was disseminating the change in a meaningful way during a time of high census and limited staffing due to the COVID-19 pandemic. Complex adaptive systems theory was used to plan interventions in these conditions.
  10. Content Article
    This factsheet explains more about how the new independent Health Service Safety Investigations Body (HSSIB) will function
  11. Content Article
    Black and Asian bereaved parents whose baby died during pregnancy or shortly after birth have shared their experiences as part of the Sands Listening Project. The 56 parents who took part shone a light on care that works well, while also highlighting barriers, biases, and poor care. In the report, published by Sands, you can read more about: the findings pregnancy loss and baby deaths among Black and Asian babies in the UK real-life experiences and case studies what needs to change. Follow the link below to access the Listening Project report on the Sands website. 
  12. News Article
    NHS England has demanded recovery plans from six systems with a poor record on delivering urgent cancer checks. NHS England has told the chief executives of the six integrated care boards they must “present and deliver a plan” to make more use of their diagnostic facilities for patients who need urgent cancer checks. The “facilities” referred to are all community diagnostic centres. The six were selected because they diagnosed or ruled out fewer than 70% of urgent cancer referrals within 28 days during February. This benchmark is known as the “faster diagnostic standard”. A letter to the chief executives said: “improving waiting times for patients referred for urgent suspected cancer will be a critical priority for the NHS over the coming year”. It adds: “it is essential… our national investments in diagnostic capacity are more clearly prioritised for patients being investigated for urgent suspected cancer”. Read full story (paywalled) Source: HSJ, 28 April 2023
  13. News Article
    Patients who have had older types of hip replacement may be at greater risk of heart damage than previously thought, researchers have said, because of cobalt leaching out of so-called metal-on-metal implants. Tens of thousands of UK patients were fitted with these devices during the 2000s, when they were marketed as a solution for young, active patients who needed a hip replacement that would last a lifetime. The issue is that tiny metal ions made up of cobalt and chromium are thought to break off from the implants and leak into the blood, and there are fears this could cause muscle, bone and organ damage. Surgeons began to voice concerns about the implants in 2008, and in 2012 the Medicines and Healthcare products Regulatory Agency (MHRA) issued guidance recommending annual blood or MRI checks for patients who had received them. Since then, mounting evidence has suggested that such individuals may be at greater risk of heart disease. Read full story Source: The Guardian, 26 April 2023
  14. News Article
    Young doctors just out of medical school working as resident physicians, fellows and interns at major US hospitals are organising unions at an increasing rate, citing long-running problems highlighted by the Covid-19 pandemic and a need to rethink the struggles young doctors face in the profession. The Committee of Interns and Residents, an affiliate of SEIU, added five unionised sites in 2022 compared with about one a year before the pandemic and the surge has continued in 2023 with multiple union election filings. It currently represents over 25,000 residents, fellows and interns across the US, comprising about 15% of all resident and fellow physicians. Hospital management has opposed the unionisation effort, declining to voluntarily recognise the union, encouraging residents not to sign union authorisation cards ahead of the election filing and writing local op-eds in opposition to unionisation. Since going public with their union plans, staff have been sent emails and been invited to meetings to try to dissuade residents from unionising, “often counting on myths around what unionizing would mean”, said Dr Sascha Murillo, a third-year internal medicine resident at Massachusetts general hospital. The unionising campaign took off after vulnerabilities in the healthcare system were exposed by the Covid-19 pandemic, she said, with residents working on the frontlines and bearing the brunt of staffing shortages, an influx of Covid-19 patients, and patients who deferred medical care. Read full story Source: The Guardian, 27 April 2023
  15. News Article
    The blanket use of antibiotics in farming has led to the emergence of bacteria that are more resistant to the human immune system, scientists have warned. The research suggests that the antimicrobial colistin, which was used for decades as a growth promoter on pig and chicken farms in China, resulted in the emergence of E. coli strains that are more likely to evade our immune system’s first line of defence. Although colistin is now banned as a livestock food additive in China and many other countries, the findings sound an alarm over a new and significant threat posed by the overuse of antibiotic drugs. “This is potentially much more dangerous than resistance to antibiotics,” said Prof Craig MacLean, who led the research at the University of Oxford. “It highlights the danger of indiscriminate use of antimicrobials in agriculture. We’ve accidentally ended up compromising our own immune system to get fatter chickens.” Read full story Source: The Guardian, 25 April 2023
  16. Content Article
    The US Roadmap to Health Care Safety for Massachusetts sets five goals that will be reached through a sustained, collective state-wide effort among provider organisations, patients, payers, policymakers, regulators, and others.
  17. Content Article
    Adherence to best practices for sepsis management at a small community hospital was below system, state and national benchmarks and affected vital indicators, including mortality. This study carried out by Megan Kiser aimed to improve sepsis best practice compliance by implementing human factors–influenced interventions.
  18. Content Article
     Failure to rescue is defined as mortality after complications during hospital care. Incidence ranges 10.9%–13.3% and several national reports such as National Confidential Enquiry into Patient Outcomes and Death and National Institute of Clinical Excellence CG 50 highlight failure to rescue as a significant problem for safe patient care. To avoid failure to rescue events, there must be successful escalation of care. Studies indicate that human factors such as situational awareness, team working, communication and a culture promoting safety contribute to avoidance of failure to rescue events. Understanding human factors is essential to developing work systems that mitigate barriers and facilitate prompt escalation of care. This qualitative evidence synthesis identifies and synthesise what is known about the human factors that affect escalation of care.
  19. News Article
    Discrimination and inequality are bigger factors for staff wanting to leave acute trusts than burnout, new analysis of this year’s NHS staff survey has found. Researchers at LCP compared 12 summary indicators within the survey to answers on intention to leave, to build a “relative importance model” to explain “nearly 85% of the variation in intention to leave”. LCP said: “Approximately 30 per cent of that explained variance is attributable to the diversity and equality score (compared to less than 10 per cent attributable to the burnout summary indicator score).” Natalie Tikhonovsky, an analyst in LCP’s Health Analytics team, said: “Our analysis reveals a grim picture of low satisfaction levels and higher staff turnover rates currently facing the NHS acute sector. Understanding what is driving this will be key to the success of the government’s new workforce plan and to the overall aim of reducing steadily increasing wait lists.” Read full story (paywalled) Source: HSJ, 28 April 2023
  20. News Article
    A hospital trust has said its staff have been verbally abused when contacting some patients to postpone their appointments because of next week’s nursing strike. Oxford University Hospitals Foundation Trust posted a statement to its website yesterday, which said: “It is very regrettable that we have to report that our staff have been verbally abused when contacting some patients to postpone their appointments. We fully understand and appreciate how disappointing and frustrating any postponement is, and we only do this if we absolutely have to in order to provide safe care for all our patients. “Our staff are doing their best in challenging circumstances to make sure you are informed as soon as possible. We do not tolerate abuse of our staff and abuse will be noted and further action may be taken.” Read full story (paywalled) Source: HSJ, 27 April 2023
  21. News Article
    Almost one in three UK doctors investigated by the General Medical Council (GMC) think about taking their own life, a survey has found. Many doctors under investigation feel they are treated as “guilty until proven innocent” and face “devastating” consequences, the Medical Protection Society (MPS) said. Its survey of 197 doctors investigated by the GMC over the last five years found: 31% said they had suicidal thoughts. 8% had quit medicine and another 29% had thought about doing so. 78% said the investigation damaged their mental health. 91% said it triggered stress and anxiety. The MPS, which represents doctors accused of wrongdoing, accused the GMC of lacking compassion, being heavy-handed and failing to appreciate its impact on doctors. Read full story Source: The Guardian, 27 April 2023
  22. News Article
    The trust at the centre of a maternity scandal is trying to reduce the number of births at its main maternity units by 650 a year following a highly critical Care Quality Commission (CQC) visit. East Kent Hospitals University Foundation Trust is looking at ways to reduce pressure on staff at the William Harvey Hospital in Ashford, including stopping bookings from women who are “out of area”. The unit currently has around 3,600 births a year, of which 200 are out-of-area bookings. The trust is also seeking to send more births to its other site, in Thanet. It comes after the CQC used enforcement powers to order immediate improvements at the unit, following a visit in January, when it had “significant concerns about the ongoing wider risk of harm to patients”. Earlier this year, the trust’s new chief executive, Tracey Fletcher, held what board papers describe as an “emotional” meeting with 135 midwives, other staff and senior Royal College of Midwives representatives. She was told by staff that the service at the WHH was not felt to be safe due to a lack of substantive staff, high acuity of patients and the level of activity. Read full story (paywalled) Source: HSJ, 28 April 2023
  23. News Article
    A 48-hour strike by nurses in England over the Bank Holiday weekend will be cut short by a day after a High Court judge ruled it was partly unlawful. The walkout in a row over pay by the Royal College of Nursing, due to start on Sunday, will now end on Monday. RCN chief Pat Cullen said this was "the darkest day" of the dispute so far and the government needed to negotiate. Downing Street said it was "regrettable" the government had to go to court and it had tried to avoid it. Health Secretary Steve Barclay took legal action after NHS Employers said the last day of the planned strike was not covered by the mandate as the ballots closed on 2 November at midday. The judge Mr Justice Linden ordered the RCN to pay the costs of the hearing, saying the union had showed "a high degree of unreasonableness", the outcome was "inevitable" and "instead of grasping the nettle and conceding" it had forced the case to court. Read full story Source: BBC News, 27 April 2023
  24. News Article
    Four carers have been found guilty of ill-treating patients at a secure hospital, following a BBC Panorama investigation. Nine former staff at Whorlton Hall, near Barnard Castle, County Durham, had faced a total of 27 charges. Five of those on trial have been cleared. Jurors heard vulnerable patients were mocked and treated with "contempt". Lawyers for the defendants argued their clients had been doing their best in very challenging circumstances. The men found guilty have been bailed and will be sentenced at Teesside Crown Court in July. Speaking after the verdicts, Christopher Atkinson, of the Crown Prosecution Service, said the four men had a "duty of care for patients who, due to significant mental health issues, were wholly dependent on their support every day of their lives". He said it was "clear" there were times when the care provided was "not only devoid of the appropriate respect and kindness required but also crossed the line into criminal offending". Read full story Source: BBC News, 27 April 2023
  25. Content Article
    There has been a steady increase in the numbers of people dying at home in recent years. These trends became entrenched during the pandemic, which could reflect people fearful of Covid-19 in hospitals and care homes just as much as broader patient preferences for dying at home. So did those dying at home receive the care they needed, at a good standard? This new research from the Nuffield Trust sheds light on the services used by people who died at home in England, before and during the first year of the pandemic.
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