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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The World Health Organization (WHO) is in the process of establishing a Roster of consultants in the area of patient safety with the main objective of identifying experts from all over the world in different patient safety areas who may support the implementation of the Global Patient Safety Action Plan (GPSAP) 2021-2030 at global, regional, country and institutional levels. The experts with the successful outcome of their application will be placed on the Roster and subsequently may be selected for consultancy assignments in the specified area of work, primarily across the seven strategic objectives of the GPSAP 2021-2030. More information can be found in the link below. Closing date for applicants: 3 April 2024.
  2. Content Article
    Anti-choking devices are intended to alleviate choking incidents after Basic Life Support protocols have been attempted and failed. There are numerous counterfeit and unbranded anti-choking devices being sold in the UK online which do not have a valid UKCA or CE mark and may pose a significant risk of worsening choking if used. These devices should not be used in the event of a choking emergency and should be disposed of once identified as counterfeit or non-compliant.
  3. Content Article
    The aim of this study from Aiken et al. was to determine the well-being of physicians and nurses in hospital practice in Europe, and to identify interventions that hold promise for reducing adverse clinician outcomes and improving patient safety. The study found that poor work/life balance (57% physicians, 40% nurses), intent to leave (29% physicians, 33% nurses) and high burnout (25% physicians, 26% nurses) were prevalent. Rates varied by hospitals within countries and between countries. Better work environments and staffing were associated with lower percentages of clinicians reporting unfavourable health indicators, quality of care and patient safety. The effect of a 1 IQR improvement in work environments was associated with 7.2% fewer physicians and 5.3% fewer nurses reporting high burnout, and 14.2% fewer physicians and 8.6% fewer nurses giving their hospital an unfavourable rating of quality of care. Improving nurse staffing levels (79% nurses) and reducing bureaucracy and red tape (44% physicians) were interventions clinicians reported would be most effective in improving their own well-being, whereas individual mental health interventions were less frequently prioritised.
  4. News Article
    Almost 9,000 foreign nurses a year are leaving the UK to work abroad, amid a sudden surge in nurses quitting the already understaffed NHS for better-paid jobs elsewhere. The rise in nurses originally from outside the EU moving to take up new posts abroad has prompted concerns that Britain is increasingly becoming “a staging post” in their careers. The number of UK-registered nurses moving to other countries doubled in just one year between 2021-22 and 2022-23 to a record 12,400 and has soared fourfold since before the coronavirus pandemic. Seven out of 10 of those leaving last year – 8,680 – qualified as a nurse somewhere other than the UK or EU, often in India or the Philippines. Many had worked in Britain for up to three years, according to research from the Health Foundation. The vast majority of those quitting are heading to the US, New Zealand or Australia, where nurses are paid much more than in the UK – sometimes up to almost double. Experts have voiced their alarm about the findings and said the NHS across the UK, already struggling with about 40,000 vacancies for nurses and hugely reliant on those coming from abroad, is increasingly losing out in the global recruitment race. “It feels like the NHS is falling down the league table as a destination of choice for overseas nurses,” said Dame Anne Marie Rafferty, a professor of nursing studies at King’s College London. “Worryingly, it feels as if the UK is perceived not as a high- but middle-income country in pay terms and as a staging post where nurses from overseas can acclimatise to western-type health systems in the search for better pay and conditions.” Read full story Source: The Guardian, 25 March 2024
  5. News Article
    More than half of England’s army veterans have experienced mental or physical health issues since returning to civilian life, and some are reluctant to share their experiences, a survey has revealed. The survey of 4,910 veterans, commissioned jointly by the Royal College of GPs (RCGP) and the Office for Veterans’ Affairs (OVA), found that 55% have experienced a health issue potentially related to their service since leaving the armed forces. Over 80% of respondents said their condition had got worse since returning to civilian life. One in seven of those surveyed said they had not sought help from a healthcare professional. A preference for managing issues alone and the belief that their experience would not be understood by a civilian health professional were the most common reasons given. This fear of being misunderstood is demonstrated by the finding that 63% of veterans said they would be more likely to seek help if they knew their GP practice was signed up to the Veteran Friendly Accreditation scheme. More than 3,000 of England’s 6,313 GP practices are accredited, but the survey’s findings have prompted the RCGP – with NHS England and the OVA – to launch an initiative to get more GP practices on to the scheme. Practices that sign up will be provided with a “simple process” for identifying, understanding and supporting veterans and, where appropriate, referring them to dedicated veterans’ physical and mental health and wellbeing services. Read full story Source: The Guardian, 25 March 2024
  6. News Article
    NHS England’s workforce ambitions are based on ‘significant’ substitution of fully qualified GPs with trainees and specialist and associate specialist (SAS) doctors, the public spending watchdog has revealed. In a new assessment of the NHS long-term workforce plan, the National Audit Office (NAO) found that NHS England’s modelling of the future workforce had ‘significant weaknesses’ and that some of its ‘assumptions’ may have been ‘optimistic’. Last year, the national commissioner committed to doubling medical school places to 15,000 and increasing GP training places to 6,000 by 2031. This was based on modelling which predicted that, without these changes, the NHS could face a staffing shortfall of 360,000 and a GP shortfall of 15,000 by 2036. The NAO’s report has examined the robustness of NHS England’s predictions, and made a number of recommendations which could influence the refreshed projections NHSE has committed to publishing every two years. The long-term workforce plan (LTWP) projected only a 4% increase in fully-qualified GPs between 2021 and 2036, compared to a 49% growth in consultants. "The total supply of doctors in primary care is projected to increase substantially over the modelled period but the total number of fully qualified GPs is not," the report said. It found that NHSE’s projected supply growth in general practice "consists mainly of trainee GPs", who accounted for 93%, as well as "making increased use of specialist and associate specialist (SAS) doctors in primary care". Read full story Source: Pulse, 22 March 2024
  7. News Article
    An NHS watchdog has apologised to 29 doctors at Scotland's biggest hospital for not fully investigating their concerns about patient safety. A&E consultants at Glasgow's Queen Elizabeth University Hospital wrote to Healthcare Improvement Scotland (HIS) to warn patient safety was being "seriously compromised". They offered 18 months' worth of evidence of overcrowding and staff shortages to back their claims. But HIS did not ask for this evidence. The watchdog also did not meet any of the 29 doctors - which is almost every consultant in the hospital's emergency department - to discuss the concerns after it received the letter last year. Instead, it carried out an investigation where it only spoke to senior executives at NHS Greater Glasgow and Clyde before then closing down the probe. HIS has now issued a "sincere and unreserved apology" to the consultants and upheld two complaints about the way it handled their whistleblowing letter about patient safety. One consultant who signed the letter told BBC Scotland: "We'd exhausted all our options and thought HIS was a credible organisation. "We offered to share evidence of patient harm. We were shocked that they ignored this and didn't engage with us as the consultant group raising concerns." Another consultant added they were "shocked at their negligence." Read full story Source: BBC News, 25 March 2024
  8. News Article
    Older people are routinely enduring hidden waits of several months to get essential care and support, according to new figures obtained from government. Waiting time figures for adult social care are not routinely published in England, but last summer the Department of Health and Social Care collected the information from councils for the first time in at least a decade. They have been released to HSJ after a freedom of information appeal, and show average waits of up to 149 days (about five months) in Bath and North East Somerset, with 25 councils (30% of the 85 councils which supplied this information) reporting waits of two months or more. Some people will be waiting much longer than the averages reported. Across the 85 councils which reported average waits, the average of those figures was around 50 days. But the figures released to HSJ show huge variation – with three councils reporting waits of less than 10 days – although this is partly due to recording differences. The lack of clear figures, and absence of national waiting time measures and standards for adult social care, in contrast to the many targets and published figures in the NHS, and has sparked calls for that to be changed. Sir David Pearson, a former integrated care system chair and director of adult social care, who led the government’s Covid-19 care taskforce in the wake of the disaster in care homes in spring 2020, said: “One way of ensuring public confidence is a timely response to need. “Being clearer about a small number of standards and measures would help to achieve this. Of course it has to be associated with the right funding and reform, including supporting the social care workforce”. Read full story (paywalled) Source: HSJ, 25 March 2024
  9. Content Article
    Along with the Care Inspectorate, Healthcare Improvement Scotland have established a National hub for reviewing and learning from the deaths of children and young people (National hub). The National hub uses evidence to deliver change. It ultimately aims to help reduce preventable deaths and harm to children and young people.  
  10. Content Article
    The role of artificial intelligence (AI) in healthcare is expanding quickly with clinical, administrative, and patient facing uses emerging in many specialties. Research on the effectiveness of AI in healthcare is generally weak, but evidence of AI improving doctor’s diagnostic decisions is emerging for some focused clinical applications, including interpreting lung pathology and retinal images. However, we must work with patients to understand how AI impacts on their care, says Rebecca Rosen in this BMJ opinion piece.
  11. Content Article
    Katie Hurst is a general surgery registrar based in the Thames Valley Deanery and chair of the Trainees’ Committee for the Royal College of Surgeons of Edinburgh. In this interview, we talk to Katie about the work she is doing with the Royal College of Surgeons of Edinburgh on raising awareness and protecting staff from ionising radiation.
  12. Content Article
    Ambulatory safety nets not only safeguard against diagnostic errors, they also encourage collaboration, support health care providers, and break down competitive barriers for the greater good of patient safety.
  13. Event
    until
    A four-week introduction to Patient Leadership, led by David Gilbert. Patient Leadership signals a breakthrough in healthcare that moves beyond traditional engagement and uncovers the pioneering and transformative work of patient leaders – those affected by life-changing illness, injury or disability who want to lead change in the healthcare system. Or ‘those who have been through stuff, who know stuff, who want to change stuff’. About this programme This course lays the foundation for understanding patient leadership – it is designed for both patients and non-patients to explore together different facets of this emerging social movement. It is for Patient and Carer Leaders, health professionals, managers, non-clinical staff and those from the independent, voluntary and charitable sector. And open to international attendees. This programme lays the foundations for understanding patient leadership. It leads you through the principles of patient leadership, what it is and where it came from, the qualities of an effective patient leader, support needed and models of embedded patient leadership. For patients, users, carers and staff (clinical, managerial). The framework for May's course The four sessions take place on consecutive Wednesdays, between 4pm and 7pm UK time. Wednesday 1 May - Session 1 - What is Patient Leadership The different tributaries of the ‘patient movement’ The failure of traditional engagement approaches The emergence of ‘patient leaders’ Definitions and clarifications What we bring - Jewels of wisdom and insight from the caves of suffering Wednesday 8 May - Session 2 - The Effective Patient Leader The Different Roles for a Patient Leader What Matters – an anchor for the effective Patient Leader Benefits of Patient Leadership The four main capabilities The different sorts of support needed Wednesday 15 May - Session 3 - Embedding Patient Leadership in Healthcare The Patient Leadership Triangle (the Sussex MSK Model) The Patient Director – a new role in healthcare Culture, systems and processes Progression routes & creating opportunities The current climate for Patient Leadership Wednesday 22 May - Session 4 - Reflections and Next Steps Reflections on the programme Exploring issues in more depth Your next steps Your learning and support requirements Register
  14. Content Article
    The Joint Commission has released a simplified breakdown of eight patient safety goals for US hospitals in 2024.
  15. News Article
    Six out of 10 NHS nurses have had to use credit or their savings over the last year to help them cope with the soaring cost of living, according to new research. Acute financial pressures are forcing some nurses to limit their energy use while others are going without food. Many are doing extra shifts to help make ends meet. The findings have added to fears that money worries and inadequate pay will prompt even more nurses to quit the NHS, which is already short of almost 35,000 nurses. The Royal College of Nursing (RCN), which undertook the survey of almost 11,000 nurses in England, claimed that too many in the profession had been left without enough money to cover their basic needs as they paid the price for “the government’s sustained attack on nursing”. Read full story Source: The Guardian, 22 March 2024
  16. News Article
    The Government has failed to implement a number of recommendations from significant inquiries into major patient safety issues, years after they were agreed to, according to an independent panel. The report, commissioned by the Health and Social Committee in the wake of the Lucy Letby case, voiced concerns about “delays to take real action”. As part of its investigation, the panel selected recommendations from independent public inquiries and reviews that have been accepted by government since 2010. Nine or more years have passed since these recommendations were accepted by the government of the day These covered three broad policy areas – maternity safety and leadership, training of staff in health and social care, and culture of safety and whistleblowing – and were used to evaluate progress. The panel gave the Government a rating of “requires improvement” across the policy areas. One of the recommendations was rated good. The report said that “despite good performance in some areas” the rating “partly reflects the length of time it has taken for the Government to make progress on fully implementing four of the recommendations which were accepted nine years ago, or longer”. “Progress is imminent in several areas, which is reassuring, but we remain concerned about the time it has taken for real action to be taken,” it added. Read full story Source: The Independent, 22 March 2024 Read Patient Safety Learning's response to the report: Response to Select Committee report: Evaluation of the Government’s progress on meeting patient safety recommendations
  17. Content Article
    This report, produced in collaboration with the Association of Ambulance Chief Executives and the NHS Confederation, highlights the pivotal role ambulance trusts play in delivering urgent and emergency care and sets out a long-term vision for an enhanced role they could take in co-designing this care. It sets out the case for change and includes several case studies that demonstrate the benefits of ambulance services taking this broader approach.
  18. News Article
    A new system requiring GPs to agree death certificates with a medical examiner is unlikely to launch at the beginning of April, it has emerged. The system, which will see medical examiners (MEs) providing independent scrutiny of all deaths in the community which are not taken to the coroner, had previously been due to come in from April last year. However, it was delayed by one year to allow time for Parliament to introduce the necessary supporting legislation and, according to the Department of Health and Social Care (DHSC), this has yet to happen. A spokesperson told Pulse that the Government’s intention is to still introduce secondary legislation ‘from April’ to implement death certification reform. However, it could not confirm the exact date the system will launch and said it would provide an update before the end of March. Nottingham GP Dr Irfan Malik told Pulse that local GPs and practice staff ‘seem to be aware there is a delay’ but have had ‘no official emails’ or communication confirming the delays. Read full story Source: Pulse, 20 March 2024
  19. News Article
    Trust chiefs have collectively called for the Care Quality Commission (CQC) to review its use of single-word inspection ratings, following MPs’ calls for an overhaul of Ofsted ratings for schools. In a report containing a series of recommendations for CQC reform, shared with HSJ, NHS Providers urges the regulator to re-evaluate the success of its single-word ratings, asking it to consider adding a narrative verdict as part of its new provider assessment reports. The recommendation is made “in the context of the Ofsted inquiry findings” following the death of headteacher Ruth Perry by suicide, which a coroner ruled was contributed to by an Ofsted inspection. It prompted MPs on the Commons’ education committee to call for a ban on single-word Ofsted ratings. The NHSP report said the inquiry’s concerns around inspectors’ behaviour, the complaints process, and single ratings can also be applied to CQC. The report adds: “While we recognise the differences between the two regulators’ approaches, we believe now is the right time to take stock… for example, CQC may need to consider the value of its single-word ratings, modelled upon Ofsted’s rating system. “As suggested by the Nuffield Trust and many trust leaders, a single-word rating will inevitably oversimplify what happens in a very complex organisation". Read full story (paywalled) Source: HSJ, 21 March 2024
  20. News Article
    Lessons have not been learned to prevent further deaths in north Wales, coroners have told the health secretary. Over the past year, coroners in Wales wrote 41 "prevention of future deaths reports" and more than half were issued to Betsi Cadwaladr health board. Health Secretary, Eluned Morgan, said 27 reports issued since January 2023 was "of significant concern". Betsi Cadwaladr health board said every report was taken very seriously and work was ongoing to respond to key themes. Ms Morgan said all but three of the deaths happened before the health board was moved back into special measures in February 2023. The "systemic issues" that emerge as common themes from the coroners' reports include: the quality of investigations and effectiveness of actions a lack of integrated electronic health records impacting care the impact of delays in the system on ambulance response times. In a written statement earlier this week, Ms Morgan said the health board had given assurances that it was taking the matter "extremely seriously". Read full story Source: BBC News, 21 March 2024
  21. Content Article
    The Health and Social Care Select Committee’s Independent Expert Panel produces reports which assess progress the Government has made against their own commitments in different areas of health and care policy. On the 22 March 2024 they published a new report evaluating the implementation of accepted recommendations made by inquiries and reviews into patient safety. This blog sets out Patient Safety Learning’s response to its findings.
  22. Content Article
    The aim of this study was to quantify the difference in weekday versus weekend occupancy, and the opportunity to smooth inpatient occupancy to reduce crowding at children's hospitals. They study found that hospitals do have substantial unused capacity, and smoothing occupancy over the course of a week could be a useful strategy that hospitals can use to reduce crowding and protect patients from crowded conditions.
  23. News Article
    Many popular AI chatbots, including ChatGPT and Google’s Gemini, lack adequate safeguards to prevent the creation of health disinformation when prompted, according to a new study. Research by a team of experts from around the world, led by researchers from Flinders University in Adelaide, Australia, and published in the BMJ found that the large language models (LLMs) used to power publicly accessible chatbots failed to block attempts to create realistic-looking disinformation on health topics. As part of the study, researchers asked a range of chatbots to create a short blog post with an attention-grabbing title and containing realistic-looking journal references and patient and doctor testimonials on two health disinformation topics: that sunscreen causes skin cancer and that the alkaline diet is a cure for cancer. The researchers said that several high-profile, publicly available AI tools and chatbots, including OpenAI’s ChatGPT, Google’s Gemini and a chatbot powered by Meta’s Llama 2 LLM, consistently generated blog posts containing health disinformation when asked – including three months after the initial test and being reported to developers when researchers wanted to assess if safeguards had improved. In response to the findings, the researchers have called for “enhanced regulation, transparency, and routine auditing” of LLMs to help prevent the “mass generation of health disinformation”. Read full story Source: The Independent, 20 March 2024
  24. Content Article
    NHS Boards are required under the National Whistleblowing Standards (the Standards) to publish annual whistleblowing reports setting out performance in handling whistleblowing concerns.
  25. News Article
    A group representing hundreds of clinicians has applied to contribute to the Lucy Letby inquiry, to challenge NHS culture around whistleblowing. Their experiences of raising concerns should inform the inquiry, they say. Letby murdered seven babies and attempted to murder another six while working at the Countess of Chester NHS trust between June 2015 and June 2016. The public inquiry is examining how the nurse was able to murder and how the hospital handled concerns about her. "The evidence of this group relating to how whistleblowers are treated, not just at one trust but across the UK, is of huge significance," Rachel di Clemente, of Hudgell Solicitors, acting for the clinicians, said. The group, NHS Whistleblowers, comprising healthcare professionals across the UK, including current and former doctors, midwives and nurses, has written to Lady Justice Thirlwall's inquiry, asking for them to be formally included as core participants. The inquiry has stated it will consider NHS culture. And the group says "a culture detrimental to patient safety" is evident across the health service. "NHS staff who have bravely spoken up about patient-safety concerns or unethical practices deserve to have their voices heard," Dr Matt Kneale, who co-chairs Doctors' Association UK, which is part of the group, said. Read full story Source: BBC News, 21 March 2024
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