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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
     In the wake of the Covid-19 pandemic, we are all too aware of the urgent health inequalities that plague our world. But these inequalities have always been urgent: modern medicine has a colonial and racist history. Here, in an essential and searingly truthful account, Annabel Sowemimo unravels the colonial roots of modern medicine. Tackling systemic racism, hidden histories and healthcare myths, Sowemimo recounts her own experiences as a doctor, patient and activist. Divided exposes the racial biases of medicine that affect our everyday lives and provides an illuminating - and incredibly necessary - insight into how our world works, and who it works for.
  2. Event
    Dr Leslie Hamilton, assistant coroner and retired cardiac surgeon, will speak about the importance of creating and maintaining a no-blame culture within NHS and independent healthcare organisations. This should help to ensure that people feel able to share and reflect honestly whenever things go wrong in care, so that lessons can be learnt and changes made to improve patient safety. Register
  3. Event
    Rhys Hadden, a barrister from Serjeants’ Inn Chambers, will consider: Key case law and important updates from the past 12 months; Any updates on the revisions to the Code of Practice to the Mental Capacity Act 2005; and What is the latest with the Liberty Protection Safeguards? Register
  4. Event
    This session will build on the concepts discussed within HSIB’s Level 2 in Safety Investigation programme and will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Enrol
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    This virtual workshop will provide health care professionals 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
  6. Event
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    This virtual workshop will provide health care professionals 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
  7. Event
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    This virtual workshop will provide health care professionals 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
  8. Event
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    The Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 2.5 hour masterclass will focus upon using SEIPS in Mental Health. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. The masterclass will be limited to a small group to ensure in-depth learning. Priced at £50 per person. Pre and post class materials will be provided. Register
  9. Event
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    The Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 2.5 hour masterclass will focus upon using SEIPS in Emergency Departments. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. The masterclass will be limited to a small group to ensure in-depth learning. Priced at £50 per person. Pre and post class materials will be provided. Register
  10. Content Article
    The NHS is in a state of crisis, with increasingly long delays for ambulances and emergency care. Often people believe that hospital delays and bottlenecks are caused entirely by the difficulty of discharging patients to social care. But there is another factor which is just as much of a problem, and which should be far easier to fix: the masses of unnecessary paperwork doctors and nurses have to fill out every day. Gordon Caldwell explores this issue in an article in the Spectator.
  11. Content Article
    Calculating nurse staffing in the acute hospital has become a key issue but solutions appear distant. Community, mental health and areas such as learning disability nursing have attracted less attention and remain intractable. This review from Leary and Punshon aimed to examine current approaches to the issue across many disciplines.
  12. Content Article
    Patients benefit from guideline-based preventive, chronic disease, and acute care, but many do not receive it. A limitation to providing high-quality care is insufficient time for primary care providers (PCPs). The aim of this study was to quantify the time needed to provide preventive care, chronic disease care, and acute care for a nationally representative adult patient panel by a PCP alone, and by a PCP as part of a team-based care model. The authors concluded that PCPs do not have enough time to provide the guideline-recommended primary care. With team-based care the time requirements would decrease by over half, but still be excessive.
  13. News Article
    More than two million patients each year have to make four or more repeat visits to their GP before they get a referral, a patient watchdog has warned. Patient safety campaigners said people faced waits of “weeks, months or even years” before officially joining NHS waiting lists, and that their health and wellbeing was suffering as a result. They warned it would also add to pressure on other services such as A&E departments. Research by Healthwatch England revealed what the patient watchdog called a “hidden waiting list”. “People wait for a GP appointment; they wait for their GP to tell them they will be referred; they wait for the hospital to confirm that referral; and then they join a hospital waiting list,” it said. “NHS statistics monitor only the hospital waiting list, leaving the steps between getting a GP referral and a letter confirming a hospital appointment as a dangerous ‘blind spot’ for the NHS and patients.” Read full story (paywalled) Source: The Times, 11 April 2023
  14. Content Article
    Nine care home workers are facing trial for neglecting, verbally abusing and deliberately antagonising extremely vulnerable patients at Whorlton Hall. The six men and three women, aged 25-54, are being prosecuted after a reporter went undercover and filmed the behaviour for a BBC Panorama documentary. George Julian repots on the case at Teesside crown court in Middlesbrough.
  15. News Article
    Covid-19 has dropped out of the top five leading causes of death in England and Wales for the first time since the start of the pandemic, figures show. Coronavirus was recorded as the main cause of death for 22,454 people in 2022, or 3.9% of all deaths registered, making it the sixth leading cause overall. In both 2020 and 2021 Covid-19 was the leading cause of death, with 73,766 deaths (12.1% of the total) and 67,350 (11.5%) respectively. By contrast, dementia and Alzheimer’s disease was the leading cause in England and Wales in 2022, with 65,967 deaths registered (11.4% of the total), up from 61,250 (10.4%) in 2021. The other causes in the top five were ischaemic heart diseases (59,356 deaths and 10.3% of the total); chronic lower respiratory diseases (29,815 deaths, 5.2%); cerebrovascular diseases such as strokes and aneurysms (29,274 deaths, 5.1%); and trachea, bronchus and lung cancer (28,571 deaths, 5.0%). Read full story Source: The Independent, 11 April 2023
  16. News Article
    Hospital bosses are worried about keeping patients safe overnight this week because of a shortage of consultants available to cover for striking junior doctors. When junior doctors in England staged their first strike in mid-March in their pay dispute with the government, their consultant colleagues covered for them for the three days involved. However, fewer consultants are available to do the same during this week’s four-day stoppage because it coincides with Easter, Passover and Ramadan and many are off. NHS Providers, which represents health service trusts, highlighted the difficulty hospital bosses are facing in trying to ensure nightshift medical rotas are fully staffed this week. T “Getting through today is just the start. Trust leaders are worried about securing adequate cover for the night shifts ahead. This is going to be a very long, difficult week for the NHS,” said Miriam Deakin, the head of policy at NHS Providers. “Keeping patients as safe as possible, trusts’ No 1 priority, will be even harder than in previous strikes so it’s all hands on deck.” Other health professionals, including GPs, paramedics and pharmacists, were helping hospitals ensure patients received good care, Deakin added. Read full story Source: The Guardian, 11 April 2023
  17. News Article
    Patients contacting NHS 111 in England are having to wait so long for medical help that they are abandoning millions of calls, with 3.6m ditched in the past 12 months, official figures reveal. The national helpline service is supposed to make it quicker and easier for patients to get the right advice or treatment they need, either for their physical or mental health. It is billed as being open 24 hours a day, seven days a week. However, analysis by the House of Commons Library, commissioned by the Liberal Democrats, shows callers are waiting so long to speak to someone that nearly one in five give up. In 2022, 3,682,516 calls to NHS 111 were abandoned. MPs said the “dire” figures exposed how the NHS had reached “breaking point” after years of “neglect and underfunding” by the government. The data suggests that, on average, more than 10,000 callers hang up every day without receiving medical advice or treatment. As well as being distressing for those who are unwell, abandoned NHS 111 calls pose a risk to patient safety. The problem also increases pressure on other urgent care services as people seek care elsewhere. Read full story Source: The Guardian, 10 April 2023
  18. Content Article
    Traditional approaches to patient safety and handoffs need redesigning to acknowledge the different constraints, goals, and requirements necessary for each individual patient. There is no “one size fits all” approach to patient safety, handoffs or a perfect checklist. Despite the inherit complexity present in healthcare systems, we tend to reduce our thinking about handoffs into simple solutions of checklists and cognitive aids. In studies of these tools, their association with patient outcomes is unclear with mixed results in large studies. Incorporating general resilience engineering principles of visibility, understanding, anticipation, and learning provides new opportunities for increased patient safety. This involves situating the handoff in the context of the system - understanding the process of summarising pre-handoff and of developing understanding post-handoff, tracing flows of information and patients, and considering the role of feedback and control loops in the system. Direct observations, analysis of multiple outcomes, focus on patient evolving specific exceptions, reducing the number of handoffs, taking time for two-way discussions, and user-centred design and redesign may promote acceptability and sustainability of a new view of handoffs for improved patient safety.
  19. Event
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    Digital technologies have transformed how health and care services are offered and used, and the better and more widespread use of these technologies bring further opportunities to improve people’s health and experiences of services. Through the lens of both the workforce and people who draw on health and care services, this event will explore how to successfully adopt digital solutions in health and care and the practical realities of implementation. At this event, you’ll have the opportunity to discuss different digital technologies, and hear how they can be used innovatively to improve service design and delivery and user experience, as well as help tackle the current pressures facing the NHS and the wider system. Join experts from The King’s Fund and across the health and care system to share best practice and consider how we can ensure the system has the skills, leadership and culture to harness digital transformation. Register
  20. News Article
    Eighteen months after April Adcox learned she had skin cancer, she finally returned to Charleston's Medical University of South Carolina last May to seek treatment. Adcox had first met with physicians at the academic medical center in late 2020, after a biopsy diagnosed basal cell carcinoma. The operation to remove the cancer would require several physicians, she was told, including a neurosurgeon, because of how close it was to her brain. But Adcox was uninsured. She had lost her automotive plant job in the early days of the pandemic, and at the time of her diagnosis was equally panicked about the complex surgery and the prospect of a hefty bill. Instead of proceeding with treatment, she attempted to camouflage the expanding cancerous area for more than a year with hats and long bangs. If Adcox had developed breast or cervical cancer, she likely would have qualified for insurance coverage under a federal law that extends Medicaid eligibility to lower-income patients diagnosed with those two malignancies. For female patients with other types of cancer, as well as pretty much all male patients, the options are scant, especially in South Carolina and the 11 other states that haven't yet implemented Medicaid expansion, according to cancer physicians and health policy experts who study access to care. In the face of potentially daunting bills, uninsured adults sometimes delay care, which can result in worse survival outcomes, research shows. The odds of patients getting insurance to help cover the cost of treatment play out a bit like a game of roulette, depending upon where they live and what type of cancer they have. "It is very random — that's, I think, the heartbreaking part about it," said Dr. Evan Graboyes, a head and neck surgeon and one of Adcox's physicians. "Whether you live or die from cancer shouldn't really be related to what state you live in." Read full story Source: CBS News, 7 April 2023
  21. Event
    NHS England are offering a flexible online course for those working to create compassionate and inclusive cultures in health and social care through collective leadership. Are you: Working in, or with, health or social care? Enthusiastic about improving the culture within your team, organisation or system for the benefit of you, your colleagues and the patients and communities we serve? A programme lead, change team member or stakeholder for your organisation or system using the Culture and Leadership Programme? Eager to connect with colleagues who are also doing this kind of work? Looking for free, flexible and bite-sized learning about culture that you can access at a desk or on the go? If so, our Nurturing Compassionate and Inclusive NHS Cultures course could be for you. This new online learning course, broken up into bite-sized components, provides you with an introduction to compassionate cultures and how to use the Culture and Leadership Programme approach and resources. It is focussed on equipping you with practical knowledge, skills and support, helping you to undertake your own culture transformation journey. The course is designed to provide ample opportunity for discussion and collaboration with peers and facilitators to provide learners with a network of support. These NHS England courses are free to take part in, and are delivered entirely online in the form of videos, articles, discussion and practical exercises that contribute to your own culture transformation journey. The programme is organised into two 2 or three 3 core learning modules (dependent on your role within your organisation’s culture transformation journey): Welcome and how to navigate these materials An overview of the Culture and Leadership Programme (CORE) Getting Started – The Scoping Phase (CORE for Programme Leads responsible for the programme in their organisation/system, optional for other learners) There is optional additional content which you can access flexibly as needed: The discovery Phase The design phase The delivery phase Additional learning resources Course dates Each course will be facilitated for one month, during which time participants will have access to the Culture Transformation Team’s topic experts for guidance and advice. There will also be a 1 hour live learning session during this month providing you with the opportunity to discuss your reflections with other learners from the course, and to have direct access to the Culture Transformation Team to ask questions. Details of this can be found within the learning materials. Learners can complete the course in their own time, with each taking around 2.5 hours in total. This can be done all together or in smaller chunks at times that work for you. Throughout the programme, participants will be prompted to reflect on the course content and are encouraged to comment on one-another’s contributions. After successfully completing the core modules of this programme, you will receive a certificate of completion for your Continuing Professional Development (CPD) records. Register
  22. News Article
    Giving women a third scan at the end of their pregnancy could dramatically reduce the number of unexpected breech births and the risk of babies being born with severe health problems, research suggests. Pregnant women in the UK have routine scans at 12 and 20 weeks only, with no further scan offered in the third trimester unless they are considered at risk of a complicated pregnancy. The researchers hope their findings could lead to a change in guidance for clinicians that will improve maternity care. Prof Asma Khalil, who led the study at St George’s, University of London, said: “For the first time we’ve shown that just one extra scan could save mothers-to-be from trauma, an emergency C-section, and their babies from having severe health complications which could otherwise have been prevented.” She said the two routine scans were “far too early” to establish how the baby would be positioned during labour. “That’s why a third scan at 36-37 weeks could be a gamechanger to pregnancy and birth care.” Read full story Source: The Guardian, 7 April 2023
  23. News Article
    The leaders of acute trusts across England have told HSJ the second junior doctor’s strike ‘feels very different’ from the first stoppage, and services are much more vulnerable because of ‘thinner’ consultant coverage. They also reported that the instruction from NHS England not to proactively cancel elective procedures and apppointments has been largely ignored by trusts. The chief executive of a large trust in the east of England said they were “more concerned about clinical safety than at any time during covid surges”. A trust CEO in the North West told HSJ this week’s stoppage “feels much more risky than the previous strike. We have managed to cover rotas but we are very stretched and concerned about short notice cancellation from agencies and short term sickness after bank holiday.” Read full story (paywalled) Source: HSJ, 11 April 2023
  24. Content Article
    Imperial College Healthcare share a poster on their strategic goals and their values and behaviours.
  25. Content Article
    This 'Kindness in healthcare' website is the home for ‘conversation for kindness’, which is a monthly meeting that was set up in the summer of 2020 by a group of colleagues and friends working in healthcare across Sweden, the UK and the USA. The initial purpose of getting together was to have some time together to continue some initial conversations around kindness, and to explore its role at the ‘business end’ of healthcare. As the conversation has developed, interest in this work has grown and it now has contributors from almost 30 different countries across the globe. The monthly virtual call takes place the 3rd Thursday of every month (6-7pm GMT) and its focus is on listening, learning, thinking differently and mobilising for action It's an open culture of sharing of resources, energy and ideas.
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