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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Trust in care homes has slumped, leaving half of the British public lacking confidence that friends or family would be well looked after. Nationwide polling for the Guardian revealed 9 out of 10 older people believe there are not enough care staff, and half have lost confidence in the standard of care homes since the start of the pandemic. The survey conducted by Ipsos this month follows a doubling in public dissatisfaction in the NHS and exposes deepening fears about the fitness of a social care sector that had its weaknesses exposed by Covid-19, which claimed 36,000 lives in care homes in England alone. The Relatives and Residents Association (RRA) said the polling tallied with calls to its helpline about the “harm and anguish caused by poor care and frustration at the inconsistency in standards”. “We must weed out the poor providers and invest in skills – care workers must become our most valued workers, not the least,” said Helen Wildbore, the RRA’s chief executive. “Tomorrow, any one of us could need them.” Read full story Source: The Guardian, 24 April 2023
  2. News Article
    More teenagers are at risk of contracting rare but serious diseases due to a fall in immunisations as a result of the pandemic, according to a report. The uptake of vaccines among teenagers in secondary schools that protect against meningococcal disease, diphtheria, tetanus and polio has dropped since COVID affected routine school immunisation programmes provided by the NHS. The UK Health Security Agency (UKHSA) found that 69% of children in year nine, aged 13 and 14, had the MenACWY vaccine and the Td/IPV booster in 2021-22. This marked a 7% drop in coverage for both vaccines compared to the previous year. The 3-in-1 Td/IPV booster helps provide teens with long-lasting protection against tetanus, diphtheria and polio, diseases that can result in serious illness or even death. Doctor Vanessa Saliba, consultant epidemiologist at UKHSA said: "In recent years we have seen vaccine uptake fall due to the challenges posed by the pandemic. "Many young people who missed out on their vaccinations have already been caught up, but more needs to be done to ensure all those eligible are vaccinated. "These vaccines offer the best protection as young people start their journey into adulthood and mixing more widely - whether going to college, starting work, travelling or going to summer festivals." Read full story Source: Sky News, 24 April 2023
  3. News Article
    Unannounced and out-of-hours spot-checks on mental health services are set to ramp up following a string of abuse scandals, The Independent can reveal. The Care Quality Commission’s new mental health chief Chris Dzikiti said he was “saddened” by “unacceptable” scandals in the last six months, warning the regulator “will use the powers [it has] to hold people to account.” He said the organisation will be carrying out more unannounced inspections of providers, including inspections launched out of normal hours, with the aim to have the “majority” of spot-checks carried out this way. In his first interview since joining the regulator in November Mr Dzikiti, who is mental health nurse by background, said: “I talk to chief execs of mental health services, I talk about [how] as a regulator, we will use the power we have, when [we] see poor practice, we will definitely hold people to account. “In our inspection programmes, we are also increasing the unannounced inspections out of hours inspections, because we need to try and get really deep into the culture of mental health services, especially those areas where we think there’s a higher risk of poor practice. “I will not rest until we get people safe.” Read full story Source: The Independent, 24 April 2023
  4. News Article
    The amount of government money spent on medical negligence cases and legal fees in Northern Ireland doubled within a year. Just over £20m was paid out during 2020-21 but that increased to more than £40m in the 2021-22 financial year. Last year, £30.7m was paid out in damages, while £5.9m went on plaintiff costs and £3.7m in defence costs. The increase in cost is being attributed to the coronavirus pandemic. Last year, 3,987 clinical negligence cases were open. Almost half (1,813) of all cases open in 2021-22 related to four specialties: Obstetrics - 564 Accident and emergency - 456 Neurology - 407 General surgery - 386 There has been a stark increase in the number of cases relating to neurology in the past five years from 23 in 2017-18 to 407 in 2021-22. Read full story Source: BBC News, 24 April 2023
  5. Content Article
    The objective of this study from Sharma et al. was to evaluate the accuracy of a new elective surgery clinical decision support system, the ‘Patient Tacking List’ (PTL) tool (C2-Ai(c)) through receiver operating characteristic (ROC) analysis. They found that the PTL tool was successfully integrated into existing data infrastructures, allowing real-time clinical decision support and a low barrier to implementation. ROC analysis demonstrated a high level of accuracy to predict the risk of mortality and complications after elective surgery. As such, it may be a valuable adjunct in prioritising patients on surgical waiting lists. Health systems, such as the NHS in England, must look at innovative methods to prioritise patients awaiting surgery in order to best use limited resources. Clinical decision support tools, such as the PTL tool, can improve prioritisation and thus positively impact clinical care and patient outcomes.
  6. Content Article
    These newsletters on LinkedIn from Hemant Patel are dedicated to raising the issue of health inequalities and population health management.
  7. Content Article
    The number of people waiting for elective healthcare is at record levels. As well as compelling moral reasons to reduce NHS waiting lists, there is also a convincing economic case to go further and faster on elective recovery. We find that delivering against the target set by the Elective Recovery Plan would deliver an estimated increase in production of £73 billion over five years. But delivering a 30% increase in elective activity is a challenging task – and not one that data suggest will happen without further policy intervention. To help identify immediate opportunities for intervention, this report from the Progressive Policy Think Tank explores the most pressing bottlenecks in the elective treatment pathways. 
  8. Content Article
    This BMJ Leader article from Roger Kline looks at how to tackle structural racism in the NHS, discussing psychological safety and inclusion, and the role leaders need to play.
  9. Content Article
    According to the World Health Organization, humanity faces its greatest ever threat: the climate and ecological crisis. Healthcare services globally have a large carbon footprint, accounting for 4-5% of total carbon emissions. Surgery is particularly carbon intensive, with a typical single operation estimated to generate between 150-170kgCO2e, equivalent to driving 450 miles in an average petrol car. The UK and Ireland surgical colleges have recognised that it is imperative for us to act collectively and urgently to address this issue. The Royal College of Surgeons of Edinburgh have collated a compendium of peer-reviewed evidence, guidelines and policies that inform the interventions included in the Intercollegiate Green Theatre Checklist. This compendium should support members of the surgical team to introduce changes in their own operating departments. The recommendations apply the principles of sustainable quality improvement in healthcare, which aim to achieve the “triple bottom line” of environmental, social and economic impacts. 
  10. Content Article
    The world is on the cusp of an ominous development: bacteria are building resistance to existing antibiotics faster than new antibiotics are entering the market. An ever-widening cavity is opening up. This 'antibiotic gap', as experts call this development, marks the beginning of a new era in medicine. For the first time in recent history, we have to come to terms with the fact that not all bacterial infections are treatable anymore - with implications for all areas of medicine, from surgery to oncology. The World Health Organization has been using the term "silent pandemic" since the fall of 2021 because, unlike Covid, antibiotic resistance is creeping into our society unnoticed - but it is shaking up our healthcare system just as overarchingly. Silent Pandemic shows how countries, scientists and private initiatives around the world are networking and forming alliances, and what strategies and measures they are using to counter the advance of antibiotic resistance.
  11. News Article
    The medical device complaint management market is experiencing significant growth due to the increasing focus on patient safety and regulatory compliance. As medical devices become more complex and the regulations governing them become more stringent, it has become essential for manufacturers to have effective complaint management systems in place to ensure the safety and satisfaction of their customers. The global medical device complaint management market is expected to grow at a CAGR of 6.3% from 2021 to 2026. One of the key factors driving the growth of the medical device complaint management market is the increasing emphasis on patient safety. In recent years, there has been a growing awareness of the potential risks associated with medical devices, and patients are increasingly demanding higher levels of safety and quality. This has led to a greater focus on complaint management among medical device manufacturers, who are now investing in advanced complaint handling systems to ensure that they are able to identify and address issues before they become major problems. Read full story Source: Digital Journal, 20 April 2023
  12. News Article
    System leaders are discussing pushing back the NHS’s target to virtually eliminate 78-week breaches from the waiting list by this month to ‘June or July’, HSJ understands. The discussions come after the service missed its original targeted trajectory of clearing the backlog by this month, as first proposed in NHS England’s elective recovery plan last February, despite a steep reduction over the past 18 months. Internal NHS forecasts suggest there will be around just over 10,000 long waiters still on the waiting list by the end of April, as HSJ first revealed last month. Senior sources said this week that this figure remained a likely position for the end of the month. HSJ understands there has not been any official communication to trusts about pushing back the 78-week target, and it was not yet clear when the centre’s expectations would be finalised. Read full story (paywalled) Source: HSJ, 21 April 2023
  13. Content Article
    Cancer patients and their carers face a multitude of challenges in the treatment journey; the full scope of how they are involved in promoting safety and supporting resilient healthcare is not known. This study from Tillbrook et al. aimed to undertake a scoping review to explore, document, and understand existing research, which explores what cancer patients and their carers do to support the safety of their treatment and care.
  14. News Article
    NHS England has launched a new framework for quality improvement and delivery, including a national board that will pick a “small number of shared national priorities”. The new document says NHSE will “establish a national improvement board, to agree the small number of shared national priorities on which NHS England, with providers and systems, will focus our improvement-led delivery work”. The review says NHSE will, among other actions: Create a “national improvement board” to “agree a small number of shared national priorities and oversee the development and quality assure the impact of the NHS improvement approach”. Set an expectation that all NHS providers, working in partnership with integrated care boards, will embed a quality improvement method aligned with the NHS improvement approach”. Incentivise a universal focus on embedding and sustaining improvement practice”, including with “regulatory incentives alongside clearer and more timely offers of support. Work with the [Care Quality Commission] to align the revised CQC well-led [inspection method] with the improvement approach. Read full story (paywalled) Source: HSJ, 21 April 2023
  15. Content Article
    How can improvement-led delivery enhance the quality of outcomes for our patients, communities and our health and care workforce? In April 2022, Amanda Pritchard requested a review of the way in which the NHS, working in partnership, delivers effectively on its current priorities while developing the culture and capability for continuous improvement. Led by Anne Eden, NHS Regional Director South East, with a steering group chaired by Sir David Sloman, Chief Operating Officer, NHS England, the review team co-developed 10 recommendations with health and care leaders that have been consolidated into three actions.
  16. Content Article
    A research paper was published in October 2021 highlighting results of Freedom of Information (FOI) Requests sent to NHS Trusts in England. The FOI Requests asked for the number of incidents of sexual assault reported by hospitals where the victim was aged over 60, and the alleged perpetrator was a member of staff. The resulting findings were that there were at least 75 reports of sexual assault on patients over 60 by hospital staff in the past five years. The findings also show that whilst the majority of victims were female, 30% were male and that a disappointing number were reported to police – only 16. Of these, 14 were closed as “No Further Action” by the police. In this viewpoint paper published in the Journal of Adult Protection, Amanda Warburton-Wynn highlights the findings of this research.
  17. Content Article
    The West of England AHSN, in partnership with NIHR ARC West and Bristol, North Somerset and South Gloucestershire Integrated Care Board (ICB), has created the Evidence Works online toolkit. Its aim is to provide step-by-step support for anyone working in health and care to find, appraise and apply evidence for service change or to develop new products, projects or pilots.  The toolkit offers a useful starting point, to help you find and access the most relevant evidence and signpost you to more information and specialist help, should you need it.
  18. Event
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    This virtual workshop will provide paramedics with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
  19. Event
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    This virtual workshop will provide paramedics with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
  20. Event
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    This virtual workshop will provide participants with background theory and hands-on practice in using a multi-incident analysis to analyse a group of medication incidents that share a common topic on day 1 and introduce a novel tool called the Medication Safety Culture Indicator Matrix (MedSCIM) on day 2. Register
  21. Event
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    This virtual workshop will provide participants with background theory and hands-on practice in using a multi-incident analysis to analyse a group of medication incidents that share a common topic on day 1 and introduce a novel tool called the Medication Safety Culture Indicator Matrix (MedSCIM) on day 2. Register
  22. Content Article
    On Saturday 17 September 2022, the fourth annual World Patient Safety Day took place, established as a day to call for global solidarity and concerted action to improve patient safety. Medication safety was chosen as the focused for World Patient Safety Day 2022 due to the substantial burden of medication-related harm at all levels of care. In this report, the World Health Organization (WHO) provides an overview of activities in the countries that observed World Patient Safety Day 2022 to make this event.
  23. News Article
    The mother of a young woman who died with herpes said she was "disgusted" with an NHS trust which "lied" about the potential cause of the virus. Kim Sampson and Samantha Mulcahy died with herpes after the same obstetrician at the East Kent Hospitals University NHS Trust carried out their caesareans. Yvette Sampson's daughter had been "fit and healthy" until she gave birth on 3 May 2018, an inquest has heard. She said the trust had lied about links between the two mothers' deaths. They were treated by the same surgeon and midwife six weeks apart, neither of whom were tested for herpes, the inquest in Maidstone was told. Ms Sampson said her daughter had been "in agony" from 3 May when she gave birth to her second child, until she died on 22 May. She told the inquest she had received "poor treatment" by midwives at the Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate, which she felt also "contributed" to her daughter's death. Ms Sampson was initially denied a Caesarean and instead told to push for almost three hours, despite repeatedly telling midwives that "something wasn't right" and "clinging to the bed in agony", her mother said. Read full story Source: BBC News, 20 April 2023
  24. Content Article
    Chronic pain is the most common complication affecting adults with sickle cell disease (SCD).Pain profoundly affects people’s quality of life, functional ability, and health care utilization. Clinicians are often unsuccessful at addressing chronic pain in SCD, especially among the large number of patients for whom nonopioid analgesics aren’t sufficient and those who have developed opioid tolerance. Why aren’t we doing better? In this perspective article in the New England Journal of Medicine, Childerhose et al. discuss how a biopsychosocial model can help capture people’s experience of chronic pain by affirming that biologic, neuropsychological, and socioenvironmental elements play a role in pain-related processes. 
  25. News Article
    The NHS has launched a legal challenge that could end in the high court to block the second day of an upcoming strike by tens of thousands of nurses. Officials at NHS Employers wrote to the Royal College of Nursing (RCN) on Wednesday saying the union’s plans for a two-day strike were unlawful. In response, it is understood the RCN has said it will “forcibly resist” employers’ attempts to seek a high court injunction designed to block the strike, which they insist is lawful. The threat raises the possibility of a high court clash between NHS lawyers backed by the government and those of the nursing union. It also highlights the increasingly bitter relationship between the government and those representing workers on the frontline of the health service. Read full story Source: The Guardian, 20 April 2023
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