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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    This new report from the British Red Cross describes how asylum seekers struggle to access the internet and lack digital tools. The British Red Cross explained that the report aims to improve understanding of the experiences of digital exclusion among people seeking asylum, and how these experiences may impact access to, and experience of, healthcare. Researchers conducted interviews with 30 people currently seeking asylum across England for the report. The researchers themselves also had lived experience of seeking asylum.
  2. Content Article
    The National Clinical Guideline for Stroke for the UK and Ireland provides authoritative, evidence-based practice guidance to improve the quality of care delivered to every adult who has a stroke in the United Kingdom and Ireland, regardless of age, gender, type of stroke, location, or any other feature. The guideline is intended for: Those providing care – nurses, doctors, therapists, care staff. Those receiving care – patients, their families, their carers. Those commissioning, providing or sanctioning stroke services. Anyone seeking to improve the care of people with stroke. The guideline is an initiative of the Intercollegiate Stroke Working Party.
  3. Content Article
    The Healthcare Safety Investigation Branch (HSIB) facilitated a half-day event on 17 March 2023 to ask how healthcare can understand and start to manage the risk of staff fatigue. Listen to a recording of the event.
  4. Content Article
    Safety culture, in formal social-scientific terms, is an object of knowledge. As such, it is part of a larger discursive practice of accident prevention, together with other objects like technical failure and human error. This study examines safety culture as an object in the discourse of accident prevention based on the Foucauldian approach. 
  5. News Article
    Today’s generation of elderly people could be the last to face the spectre of untreatable Alzheimer’s disease, according to the co-chair of the government’s new dementia mission. Hilary Evans, the chief executive of Alzheimer’s Research UK, appointed by ministers last month, said the world was “on the cusp of a new dawn” for dementia treatments that meant devastating neurodegenerative illness would no longer be regarded as an inevitable part of old age. However, she warned that an overhaul of NHS dementia care was required to ensure that patients could access the first effective Alzheimer’s drugs, which could be approved in the UK as soon as next year. Evans was appointed last month to co-chair the UK government’s national dementia initiative, which aims to draw lessons from the Covid vaccine taskforce to accelerate dementia research and comes with a commitment to double funding for dementia research to £160m a year by 2024–2025. Read full story Source: The Guardian, 26 April 2023
  6. News Article
    Patient safety investigators have issued a warning to the NHS over writing to patients only in English after a Romanian child died following missed cancer scans. The three-year-old, of Romanian ethnicity, had an MRI scan delayed after they were found to have eaten food beforehand. When the appointment for the child’s MRI scan was made by the radiology booking team, a standard letter was produced by the NHS booking system in English asking the child not to eat before the scan, despite the family’s first language being Romanian. Staff at the trust had hand-written on the patient’s MRI request sheet that an interpreter was required. “The family recognised key details in the written information, including the time, date and location of the scan,” the report said. “However, they were not able to understand the instructions about the child not eating or drinking (fasting) for a certain amount of time before the scan.” The Healthcare Safety Investigation Branch (HSIB) has urged NHS England to develop and implement new rules on supplying written appointment information in languages other than English. Read full story Source: The Independent, 27 April 2023
  7. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation focuses on the systems used by healthcare providers to book patient appointments for clinical investigations, such as diagnostic tests and scans. ‘Clinical investigation booking systems’ are used throughout the NHS to support the delivery of patient care. Healthcare services use paper-based or fully electronic systems, or a combination of the two (hybrid systems), to communicate to patients the time, date and location of their appointment. These systems also produce information for patients about actions they need to take to prepare for their appointment. Written patient communication is a key output of clinical investigation booking systems. This investigation examines the safety implications of patient communications, produced by booking systems, that do not account for the needs of the patient. In addition, it looks at why patients are ‘lost to follow-up’ after an appointment is cancelled, rescheduled or not attended. Lost to follow-up is the term used to describe a patient who does not return for planned appointments (whether for continued care or evaluations) or is no longer being tracked in the healthcare system when they should be.
  8. News Article
    Following an in-depth expert safety review of the acne drug isotretinoin (commonly known by brand names Roaccutane and Reticutan), the Commission on Human Medicines (CHM) has agreed to a number of recommendations to strengthen the safe use of the treatment. Isotretinoin is used to treat severe forms of acne, especially if there is a risk of permanent scarring. This medicine is an extremely effective last-line treatment for severe acne. However, patients and members of the public have raised concerns about suspected side effects associated with isotretinoin, including psychiatric (mental health) and sexual side effects that sometimes continue after treatment with isotretinoin has been stopped. Key recommendations include: Better information for patients and their families about the risks of isotretinoin so that they can make an informed decision before using this medicine. Consistent monitoring of a patient’s psychiatric and sexual health so that any problems are spotted earlier and there are defined routes for patients to receive help. Tighter controls on first prescribing isotretinoin to young people (aged 12 to 18) so that it is only started when doctors agree the acne is severe enough to justify it and that other standard treatments have been sufficiently tried and haven’t worked. Patient Safety Commissioner, Henrietta Hughes tweeted last night: "I welcome the new recommendations from @MHRAgovuk to strengthen the safe use of isotretinoin. Courageous patients and families have shared their experience with the review. It’s only by listening and acting that we can meet patients’ needs." Read MHRA press release, 26 April 2023
  9. Content Article
    The NHS Resolution Just and learning culture charter has been developed as a resource to support the creation of a person-centred workplace that is compassionate, safe and fair when care in the NHS goes wrong. Most of the time, care received by patients in the NHS is safe. Sometimes, even with our best intentions, things can go wrong. When things go wrong, support, care and understanding for everyone involved must be a priority. At no time is there an excuse for incivility, bullying and harassment within the NHS. We accept the evidence that the NHS will provide safer care and be a healthier place to work if we address all of the components of a learning organisation and this underpins our charter. The hope is that this charter will act as a tool to help organisations take a consistent approach towards staff in relation to incidents and errors.
  10. News Article
    A major acute trust has warned ahead of next week’s nursing strike that it will face ‘very severe staffing shortages’ in children’s A&E, with ‘as few as one nurse per ward’, much less critical care capacity, and fewer operating theatres open than on Christmas Day. Cambridge University Hospitals Foundation Trust’s medical director said in a note, seen by HSJ, that the hospital would only have 60 to 70% of its critical care beds open and that “it is not possible to guarantee patient safety on our wards over the forthcoming weekend” with severe staffing shortages in “almost all areas”. The Royal College of Nursing is planning no derogations (exceptions) to its planned 48-hour walkout, from 8pm on Sunday until 8pm on Tuesday, whereas its previous action has exempted emergency care. There have been national warnings about the significant safety threat posed, but the CUH message, sent to all staff by medical director Ashley Shaw, sets out a more stark picture of critical services scaled back. It says: ”Our current information indicates there will be a severe shortage of nurses in almost all ward areas, with as few as 1 nurse per ward per shift." Read full story (paywalled) Source: HSJ, 26 April 2023
  11. News Article
    In September 2021 Caitlin Glasgow, then 10-years-old, was diagnosed with Covid. She never fully recovered. "The rest of Caitlin's classmates all returned to school after isolating for 10 days, but she was still in bed after six weeks," recalls her mother Lorna. Lorna believes her daughter has Long Covid. She is one of 175,000 people in Scotland who say they are still affected by the illness. Lorna, who lives in Penicuik in Midlothian, said her local GP was helpful and concerned for Caitlin, but it has been difficult to understand why she hasn't recovered like her friends. "She still gets pains in her legs, that's probably the worst thing along with the fatigue. There's breathlessness, chest and tummy pain, brain fog and she gets quite light-headed at times." A report published by a Scottish government committee said tackling the stigma around long Covid needs "urgent" action. The Covid-19 recovery committee has outlined a raft of measures to improve awareness of the condition among healthcare professionals. Read full story Source: BBC News, 26 April 2023
  12. Content Article
    The COVID-19 Recovery Committee has published its report on Long Covid and post-Covid syndrome, urging the Scottish Government to take action to address the stigma surrounding the condition and improve awareness among the public and healthcare professionals. The inquiry focussed on the awareness and recognition, therapy and rehabilitation, and study and research linked to Long Covid, with the Committee noting “concern” in their findings over reports of patients being unable to get the correct diagnosis and the lack of treatment for common conditions associated with the condition. The Committee said it was “deeply saddened” to learn about the stigma faced by those with lived and living experience of Long Covid, and the report highlights the impact that the lack of awareness and recognition of Long Covid can have on those with the condition.
  13. News Article
    NHS England has told many trusts and systems they are not allowed to increase their staffing establishment in the next 12 months, HSJ has learned. Trust leaders said NHS England and the government were treating money as the “first priority” and one director, speaking anonymously, said: “The tone of the conversation [with NHSE about finance] has become intimidating and I worry that this will lead boards to take unsafe risks, and head into Mid Staffs territory.” Board papers seen by HSJ, and several senior sources, confirmed many trusts had been told by NHS England during the planning process that they were not permitted to increased their total number of planned posts, known as staffing “establishment”, for 2023-24. A chief nurse at one large acute provider said the pressure on staff numbers “doesn’t triangulate” with messages on safer staffing from regulators, including NHSE, such as the drive to increase midwife numbers over maternity safety concerns. It also contrasts with plans to expand clinical staff numbers in the promised national long-term workforce plan, the chief nurse said. Read full story (paywalled) Source: HSJ, 25 April 2023
  14. News Article
    The World Health Organization (WHO) has said that a batch of contaminated India-made cough syrup has been found in the Marshall Islands and Micronesia. The WHO said that the tested samples of Guaifenesin TG syrup, made by Punjab-based QP Pharmachem Ltd, showed "unacceptable amounts of diethylene glycol and ethylene glycol". Both compounds are toxic to humans and could be fatal if consumed. The WHO statement did not specify if anyone had fallen ill. The latest alert comes months after the WHO linked other cough syrups made in India to child deaths in The Gambia and Uzbekistan. Sudhir Pathak, managing director of QP Pharmachem, told the BBC that the company had exported the batch of 18,346 bottles to Cambodia after getting all due regulatory permissions. He said he didn't know how the product had reached the Marshall Islands and Micronesia. Read full story Source: BBC News, 26 April 2023
  15. Content Article
    Work to prepare for transition to working within the Patient Safety Incident Response Framework (PSIRF) in the Autumn of 2023 is well underway by healthcare providers across England. Written for all those involved in implementing PSIRF, this article describes some of the reasons behind the challenges being faced and suggests three principles to help navigate through this complex process and offers practical ideas to help.
  16. Content Article
    Study into patient attitudes and perspectives related to viewing immediately released test results through an online patient portal. In this survey study of 8139 respondents at four US academic medical centres, 96% of patients preferred receiving immediately released test results online even if their healthcare practitioner had not yet reviewed the result. However a subset of respondents experienced increased worry after receiving abnormal results.
  17. News Article
    “Nobody cares about me. Nobody wants to help me. I don’t want to be here anymore.” Difficult words to hear from a small child, but for Molly Tippetts, aged five with a nasty tooth infection, the outburst was the culmination of two years of pain – all because she couldn’t get an appointment to see a dentist. Molly is just one example of the UK’s dental-health crisis. An increasing number of people cannot access dental care at all; others – including children and expectant mothers – find themselves on years-long waiting lists. Even though the pandemic is over, NHS practitioners admit the country is in a crisis that shows no sign of ending. New research shows one in four people suffering from toothache put off going to the dentist because of the cost. Dentistry is now the number one issue raised with Healthwatch, the independent statutory body representing NHS patients, with four in five people who contacted them saying they found it difficult to access dental care. The Royal College of Paediatrics and Child Health recently warned that even toothbrushes were a “luxury item” for some families, and that children’s dental health was a “national disgrace”. Read full story (paywalled) Source: The Telegraph, 25 April 2023
  18. News Article
    Women in labour should be offered an alternative to an epidural spinal block injection, say new draft guidelines for the NHS. The National Institute for Health and Care Excellence (NICE) is recommending remifentanil, which is a fast-acting morphine-like drug given into a vein. Women control the medication themselves, by pressing a button to get more of the drug for pain relief. A timer ensures the user cannot administer too much of it. Women who decide to try remifentanil and do not like it could still decide to have an epidural instead if there is no medical reason why they should not. They can use gas and air, also called Entonox, which is a mix of oxygen and nitrous oxide, at the same time. NICE says having remifentanil as a treatment option has advantages - it might enable women to be more mobile than with an epidural, which makes the legs numb and weak, for example. Evidence suggests fewer epidurals might mean fewer births using instruments like forceps and ventouse vacuum suction, says NICE. Read full story Source: BBC News, 25 April 2023
  19. News Article
    Two former senior managers at a large mental healthcare provider have told the BBC they had concerns about the safety of patients and staff. The whistleblowers claim they felt pressure to cut costs and fill beds. The Priory Group, which receives more than £600m of public money each year, is the biggest single private provider of mental health services to the NHS. The company denies the claims and says it successfully treats tens of thousands of patients each year. It adds its services "remain amongst the safest in the UK". The former members of the Priory Group's senior management said that, when they were working for the company, they found it difficult to recruit or retain staff, due to poor pay and conditions. They believe this resulted in patients being placed on wards that did not have staff equipped with the right skills to handle their conditions. Read full story Source: BBC News, 26 April 2023
  20. News Article
    A senior GP has been struck off the UK medical register for an “utterly deplorable” litany of treatment failures and for “reprehensible” professional conduct that included leaving patients in the care of unprepared trainee doctors and operating without adequate professional insurance. At least two patients suffered “grave consequences” from inaction on the part of Surraiya Zia, including a man whose deteriorating condition was effectively ignored for six months, despite the fact that he “presented to Dr Zia frequently, sometimes up to three times within a week, with red flag symptoms,” said Samantha Gray, chairing the medical practitioners tribunal. The patient was eventually persuaded to seek private magnetic resonance imaging by his family. This showed widespread stage IV lung cancer that took his life within weeks. Read full story (paywalled) Source: BMJ, 21 April 2023
  21. Content Article
    With record-long waits for treatment, it has never been so important for NHS trusts to understand the level of risk to patients on the waiting lists. But while it’s one thing to assess and categorise the patients and their risks while waiting, it’s quite another to then subsequently intervene to effectively care for patients during that wait. With the use of technology, there are potentially enormous gains to be made on waiting list management, and one integrated care system is forging ahead on this front. The ICS in question is Cheshire and Merseyside. HSJ takes a look at the progress Cheshire and Merseyside are making.
  22. Event
    This one day clinical audit masterclass will provide you with a full understanding of why clinical audit is important to organisations, teams and individuals (e.g. helping to meet your revalidation requirements). Short activities will help you understand how clinical audit relates to research, service evaluation and other current quality improvement techniques. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  23. Event
    This one day clinical audit masterclass will provide you with a full understanding of why clinical audit is important to organisations, teams and individuals (e.g. helping to meet your revalidation requirements). Short activities will help you understand how clinical audit relates to research, service evaluation and other current quality improvement techniques. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  24. Event
    This one day clinical audit masterclass will provide you with a full understanding of why clinical audit is important to organisations, teams and individuals (e.g. helping to meet your revalidation requirements). Short activities will help you understand how clinical audit relates to research, service evaluation and other current quality improvement techniques. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  25. Event
    Leadership in the NHS is the responsibility of all staff. This one day masterclass in Quality Improvement will allow all healthcare staff to learn about QI methodology, tools to use and how to lead change. The day has been developed to provide both practical and appropriate QI training to all staff. You will learn what QI tools to use and how to maintain the improvements. You will explore how to avoid common mistakes that staff make. Key learning objectives: Understand QI. Learn QI methodology. Develop QI skills. Learn how to lead change and avoid common resistance to change. Consider when to lead and when to follow. Ensure your QI results are maintained. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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