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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This deep-dive report on inequalities in cholesterol management by sex for patients with CVD was produced by the National Audit of Cardiovascular Disease Prevention in Primary Care (CVDPrevent). Based on data up to December 2023, it highlights two inequalities: Females with CVD were less likely than males to have a recent prescription for a lipid lowering therapy (LLT) Females with CVD were less likely to achieve threshold cholesterol levels compared to males. These inequalities were present in all age groups, in all geographic regions of England, and were consistent over time.
  2. Content Article
    During a blood transfusion and in the 12 hours following the procedure, patients sometimes experience respiratory problems or fluid in the lungs, a condition known as transfusion-associated circulatory overload (TACO). In April 2024, the Medicines and Healthcare products Regulatory Agency (MHRA) released a patient safety alert about an increasing trend of TACO-related deaths and major morbidity. This article in the journal Patient Safety looks at the occurrence of TACO and recommends strategies to mitigate the risk of patients developing the condition.
  3. Content Article
    This study used the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to explore patterns in consent and schedule errors at all hospitals and ambulatory surgical facilities (ASFs) in Pennsylvania over a four-year period. The authors also evaluated error reports for consent and schedule error subtypes: side, procedure, site and patient. Of the 1,166 event reports studied: 56% described a schedule error 34% had a consent error 10% involved both error types. In the sample of reports, the frequency of error subtypes were ranked in the following sequence: side (69%), procedure (24%), site (4%) and patient (3%). The analysis also revealed similarities and differences in the distribution of error types and subtypes across hospitals and ASFs.
  4. Content Article
    This French cohort study looked at the long-term prognosis of myocarditis after Covid-19 mRNA vaccination. It aimed to assess whether clinical outcomes and medical management differ from myocarditis following Covid infection and other origins. Using data from the French National Health Data System, all individuals aged 12 to 49 years hospitalised for myocarditis in France between December 27, 2020 and June 30, 2022 were included in the study. The authors found that people with post-vaccine myocarditis had less severe cardiovascular events than those with myocarditis of other origins at 18 months of follow-up. However, they stress that affected patients, mainly healthy young men, may require medical management up to several months after hospital discharge.
  5. Content Article
    This longitudinal cohort study aimed to assess whether variation in the composition of the nursing team on a hospital inpatient unit is associated with risk of patient death. The authors found that there was a statistically significant increase in the risk of death among patients exposed to days of low nurse staffing or high proportions of temporary staff. When low staffing was averted using temporary staff, the risk was reduced, but remained elevated compared with the baseline. This suggests that the risk of death associated with low nurse staffing is only partly reduced by using temporary staff to remedy shortfalls.
  6. Content Article
    This report by the National Child Mortality Database (NCMD) looks at deaths of children with a learning disability and autistic children aged 4-17 years. Based on data from April 2019 to March 2022, this report contains nine recommendations, including calls to ensure: reasonable adjustments are discussed with and provided for all children with a learning disability, autistic children, and where necessary their families and carers. that there is a recognition that infants and children with a learning disability and autistic children with underlying health conditions may be at higher risk of death from infection a designated Named Lead Healthcare professional is identified to support autistic children and children with a learning disability, with multiple co-morbidities and complex health care needs. there are national clinical standards and guidance relating to transition from paediatric to adult healthcare services. reasonable adjustments are made for families and carers. work is done to reduce autism assessment waiting times. children have timely access to appropriate support with mental health services. improved education about self-harm and suicide prevention. There is also a recommendation concerning payments for full-time carers of a child with a learning disability, or who is autistic, who has died. This report also highlights changes that will be introduced by the NCMD to support a deeper understanding of the deaths of children with a learning disability and autistic children in the future.
  7. Content Article
    In 2023, healthcare and public health organisations in the US reported more attacks to the FBI than any other critical and infrastructure sector. This article looks at recent cyber attacks on healthcare systems, examining their impact on patient care and exploring why healthcare is uniquely susceptible to ransomware attacks. The article goes on to outline approaches that healthcare organisations can take to improve their cybersecurity and reduce their vulnerability to attacks.
  8. Event
    until
    The predominant approach to improving safety in healthcare has involved studying adverse outcomes to identify system vulnerabilities and correct them. While this approach is useful, it has limitations. As a result of continuously investigating and analysing errors, patient safety professionals can experience stress and may view their systems and teams as unusually unsafe. This webinar will articulate the value of Success Cause Analysis (SCA) in promoting learning and organisational culture change. They will describe SCA considerations for each component of traditional event analysis, how they established SCA within their organizations, and how you can deploy SCA in your facility. Additionally, participants will learn how to mitigate “third victim syndrome” for safety professionals analysing only errors and how to involve patients and families in patient safety and quality process reviews. Speakers: Dr Komal Bajaj, chief quality officer, NYC Health + Hospitals/Jacobi and North Central Bronx Dr Lara Musser, deputy chief quality officer and practicing emergency medicine physician, NYC Health + Hospitals/Jacobi and North Central Bronx Kathy Lospinuso, RN, BSN, director of risk management at NYC Health + Hospitals/Jacobi Gayle Kolt, MPH, RN, director of risk management and regulatory affairs at NYC Health + Hospitals/Jacobi and North Central Bronx, NCB Campus Vinita Parkash, senior research scientist at the Yale School of Public Health and clinical associate professor of Pathology at Yale School of Medicine, Register for the webinar
  9. Content Article
    In this opinion piece for the BMJ, Christina Pagel, Professor of Operational Research at University College London reflects on the publication of the UK Covid-19 Inquiry's module 1 report. The report focuses on the resilience and preparedness of the UK for a pandemic. She highlights the report's finding that the UK had never planned to prevent any pandemic disease from spreading—its plans were centred on dealing with the impact of its spread and coping with a large number of deaths. The article outlines the need to determine which values drive pandemic planning and why engaging the public in national crisis planning is essential.
  10. Content Article
    More information about "Solutions to the medical practice of silencing (17 August 2024)"
    Annabel Sowemimo reviews Rageshri Dhairyawan's book Unheard: The Medical Practice of Silencing, describing it as "an honest book that expertly explores how structures, power, and care within medicine leave so many patients voiceless, as well as doctors dissatisfied with their doctor–patient encounters." The book looks at epistemic injustice, a term used to describe how patients' perspectives are ignored and belittled due to a longstanding view that they are unreliable sources of knowledge about their health. The review covers the different themes covered in Unheard including the impact of medical silencing on marginalised and vulnerable groups, how the concept of objectivity is seen in the medical community and patient advocacy.
  11. News Article
    An acute trust chief executive has warned that his organisation will struggle to “provide high-quality, timely, and financially affordable care” over the winter. The alert was contained in a message from University Hospitals of Leicester Trust CEO Richard Mitchell to the trust’s system partners. The large trust is among the worst performers against the four-hour accident and emergency target in England, and its emergency care pathway costs are already driving a deterioration in its financial deficit before the winter period. He wrote: “I am extremely concerned about our ability to provide high-quality, timely, and financially affordable care to patients this year.” Stressing the urgency of the issue, Mr Mitchell added: “There are 48 days until the start of the NHS winter (1 October) and 145 days until Monday 6 January 2025, which is likely to be the most difficult day of the period.” Speaking to HSJ, the UHL CEO said: “The UEC pathway is our greatest financial risk at UHL and any growth in demand has a negative impact on our financial position. Providing safe and effective patient care is our priority, and we were stretched to the limit in delivering that last winter. While the industrial action context has changed, and we have plans in place to improve flow and capacity, the overall picture is not different enough to alter our assessment that this year will be incredibly tough again. We need to be honest with our stakeholders and communities about that challenge.” Read full story (paywalled) Source: HSJ, 22 August 2024
  12. Content Article
    Most research to understand post acute sequelae of SARS-CoV-2 infection (PASC), or Long Covid, has focused on adults. Research is needed to characterise paediatric PASC to enable studies of underlying mechanisms that will guide future treatment. This JAMA study developed research indices for characterising paediatric PASC. The authors found that symptom patterns were similar but distinguishable between school-age children and adolescents, highlighting the importance of characterizing PASC separately in different age groups.
  13. Content Article
    The Covid-19 pandemic resulted in more falls with harms (FWH) in hospitalised patients; it has also resulted in an increased number of patients staying in isolation and receiving fewer visitors. This study aimed to look at the relationship between patient falls and visiting restrictions. The results suggest a moderately strong association between hospitalised patient FWH risk and severe visitor restrictions. This association was reduced in phases where even minor allowances for visitation were made by health services. 
  14. Content Article
    Integrated care systems (ICSs) have been in place for nearly two years and the rate of progress varies significantly across the country. This report was produced collaboratively by the Local Government and Social Care Ombudsman and the Parliamentary and Health Service Ombudsman (PHSO). It aims to help local ICSs to prioritise their citizens by focusing on how frontline services can work together for local people. Featuring case studies about people accessing services, the report focuses on two key issues that affect joint working between health and social care providers: inadequate communication between service providers secondly service providers not always putting the person at the heart of their care. Recommendations Agree a ‘person first approach’: Where it does not exist, Integrated Care Boards (ICBs), Integrated Care Partnerships (ICPs) and local authorities should design a local approach that brings councils and health services together to look at how a person’s needs can be met first, with considerations of who is responsible and who pays coming an important second. This would create a structured ‘person first’ approach that puts people before organisational structures. Use the existing tools effectively: Councils and NHS bodies must use the tools that exist effectively to support a holistic approach, such as local dispute resolution processes and the National Framework for children and young people’s continuing care. ICPs should monitor how effectively this is being done in their area. Agree standard frameworks for communication: Where they do not already exist, councils and health bodies should put in place person-centred, standard frameworks for effective communication between organisations. These should focus on ensuring the professionals on the ground interact effectively and that discussions and decisions are properly recorded.
  15. News Article
    Victims of the infected blood scandal can receive support for life, while those who were subjected to “unethical” research will get up to £15,000 extra, under changes to a multibillion-pound compensation plan. Payouts under the scheme will start by the end of the year for survivors, and by next year for affected people such as family members under a second set of regulations. Claims for those who have already died – of which there are more than 3,000 – because of the disaster can be made through their estate. Support scheme payments – including for bereaved partners – will continue for life as part of the plan, the Government said, as it announced it had accepted the “majority” of recommendations from an independent review. Victims who were used for research without their knowledge will also be eligible for an extra £10,000, with a higher award of £15,000 for those who underwent treatment as children in a notorious case at Lord Mayor’s Treloar’s College. Infected people – both living and dead – will start receiving payments through the new framework by the end of this year, while for others affected by the scandal, payments will begin in 2025, the Cabinet Office said on Friday. It comes after senior barrister and interim chairman of the compensation authority Sir Robert Francis KC made 74 proposals to address concerns with the current compensation plans. These included an enhanced award for those involved in a “particularly egregious” case of unethical testing at the Treloar school and an increase in the “social impact” payment for some of those affected. Pupils at the college were treated for haemophilia using plasma blood products infected with HIV and hepatitis, and NHS clinicians continued with treatments to further their medical research despite knowing the dangers, the Infected Blood Inquiry found. Jason Evans, who set up the Factor 8 campaign group after losing his father to the scandal aged four, said: “Compensation for those impacted by the infected blood scandal has taken far too long and too many have died waiting. “Today, the picture of what compensation might look like has become clearer, and now it must be delivered.” Read full story Source: Medscape, 16 August 2024
  16. Content Article
    This report by Kidney Research UK brings together evidence from people affected by kidney disease, health professionals and researchers. It sets out recommendations for the research community and priorities identified by patients, to move us towards equitable kidney health for all. Read the lay summary
  17. Content Article
    This rapid response by consultant psychiatrist Rachel Gibbons responds to a BMJ article about the murders of Barnaby Webber, Grace O’Malley-Kumar, and Ian Coates by Valdo Calocane, who had schizophrenia.  She outlines her concerns about coverage of the case, citing the CQC report and coverage of the case on BBC Radio 4. She highlights the difficult position healthcare professionals now find themselves in and outlines the need to manage public expectations of how mental health services are able to manage risk in the context of a system with resource constraints. Dr Gibbons states that there is a danger in making a "comparison between idealised standards of mental health care and the realities faced by healthcare providers."
  18. News Article
    Federal authorities are preparing to approve updated coronavirus vaccines targeting the latest virus variants late next week, a move that could make shots available before Labor Day, according to a federal health official and a person familiar with the plans who spoke on the condition of anonymity to discuss a confidential process. The mRNA shots manufactured by Pfizer-BioNTech and Moderna designed to target the KP.2 variant can hit the market within days of approval by the Food and Drug Administration. A third protein-based vaccine made by Novavax, preferred by people who are cautious about mRNA vaccines or who have had bad reactions to them, will probably take longer to be approved and will be distributed in subsequent weeks, according to the federal health official. The arrival of new vaccines comes three months after the start of a summer covid wave that is receding in some places. The timing of the release is too late for Americans who were looking to shore up their immunity before summer travel and the return of the school year, or for those who face heightened risk because of their age or underlying conditions. In recent weeks, some people weighed whether to get an outdated vaccine for partial protection more quickly or to hang on for the updated version. And those who didn’t want to wait discovered existing shots were no longer easy to find. “That’s simply unfortunate timing, given the high levels of covid-19 circulating now and the large number of vulnerable people due for vaccination who didn’t get it months ago and are now motivated and anxious,” said Kelly Moore, president and CEO of Immunize.org, an organization that educates clinicians about vaccines. Read full story (paywalled) Source: Washington Post, 16 August 2024
  19. News Article
    System leaders have warned that too many nationally set targets focusing on acute trusts are “constricting” efforts to tackle widening gaps in healthy life expectancy. An NHS Confederation and Institute for Public Policy Research report published today shows the gap in health life expectancy – the number of years a person can expect to live in full health – has now grown to more than 20 years between local authorities across the UK. System leaders told the report, which has been shared with HSJ, that national targets for ICSs too focused on acute rather than preventive outcomes are “constricting change” around improving health expectancy. The report adds that a “smaller set of targets may be beneficial” to tackle the widening health expectancy gap between local areas. It says: “Despite rhetoric on subsidiarity, local systems are still subject to a proliferation of targets. In turn, those targets tend to be focused on acute rather than preventative outcomes, constricting change.” The report engaged with four integrated care systems – West Yorkshire, North East London, Sussex and Coventry and Warwickshire – and the Hywel Dda University Health Board in Wales. It found that health inequalities are “highly localised” meaning that systems are key to progress. However, it argued that ICS long-term working can be “blown off course by what politicians see as burning priorities”. This is usually waiting lists and emergency department performance “rather than population health outcomes that take time to change and deliver prosperity. High turnover of health secretaries, short-termism in Treasury and the politicisation of the NHS are all challenges here. Providing long-term funding, space to experiment and political acknowledgement that real change takes time would be useful,” the report continued. Read full story (paywalled) Source: HSJ, 16 August 2024
  20. News Article
    People travelling to areas affected by the recent mpox outbreak in Africa have been urged to get vaccinated by the EU’s public health body. European Centre for Disease Prevention and Control (ECDC) updated its advice to people going to “epidemic areas” to “consult their healthcare provider or travel health clinic regarding eligibility for vaccination against mpox”. The alert comes after the World Health Organization (WHO) declared a global emergency as cases of the disease surge. This week WHO director-general Tedros Adhanom Ghebreyesus described the emergence and spread of a new variant of mpox as “very worrying”. More than 17,000 mpox cases and at least 571 deaths have been confirmed in Africa this year alone, and at least two cases have now been confirmed outside of the continent. A new strain, named clade 1, has been identified and is spreading through physical contact. WHO says it has been identified in Burundi, Kenya, Rwanda and Uganda – all countries that have never reported cases of mpox before. One case of this new strain has now been detected in Sweden, the country’s public health agency has confirmed. They say the person, who is now in isolation, had contracted it during a stay in an African country where other cases have been reported. Mpox belongs to the same family of viruses as smallpox but causes milder symptoms like fever, chills and body aches. People with more serious cases can develop characteristic lesions on the face, hands, chest and genitals. Pamela Rendi-Wagner, director of ECDC, said: “As a result of the rapid spread of this outbreak in Africa, ECDC has increased the level of risk for the general population in the EU/EEA and travellers to affected areas. Due to the close links between Europe and Africa, we must be prepared for more imported clade I cases.” Read full story Source: Independent, 19 August 2024
  21. News Article
    The number of children being treated for an eating disorder has doubled over the past eight years, with some waiting more than a year for treatment, NHS data has revealed. In the past school year there were 10,606 children beginning treatment for an eating disorder, compared with 5,240 patients in 2016-17. Waiting times for treatment are rising, with 12 per cent waiting more than three months for an appointment, compared with 1 per cent three years ago, according to information disclosed by the House of Commons Library. It is three times longer than the NHS waiting times standard, which states that children should wait no longer than four weeks for treatment to commence and no longer than one week following an urgent referral. However, some are waiting for more than a year. The longest time that a patient spent on the waiting list to receive treatment for their eating disorder was 378 days at Coventry and Warwickshire Partnership NHS Trust, according to data uncovered by Freedom of Information requests submitted by the Liberal Democrats. The Lib Dems are pushing to establish walk-in mental health hubs for young people in every community and mental health professionals in every primary and secondary school. Hope Virgo, a mental health campaigner who survived anorexia and founded the DumpTheScales campaign, said many medical professionals do not believe children when they come for help. “Through my campaigning every day I hear more and more stories of young people and adults being diagnosed with eating disorders and unable to get support,” she said. “People with eating disorders are often being told they are not sick enough for treatment and by the time they come back for support, they are told they are too sick.” Read full story (paywalled) Source: The Times, 19 August 2024 Related reading In conversation with Hope Virgo: “The withdrawal of treatment from people with eating disorders is a national crisis that’s being ignored.”
  22. News Article
    GPs in England have launched a work-to-rule action in a dispute with the government over what they say is a lack of funding. It threatens to bring chaos to the system. The British Medical Association (BMA) announced the action earlier this month, and surgeries are now taking a variety of steps, with some limiting the number of patients each GP can see to 25 per day. That could reduce the number of available appointments by a third. But with many patients already finding it difficult to get to see a doctor, there's increasing concern it could put patients at risk. Dr Tom Gorman says taking part in the work-to-rule is a last resort, but he feels compelled to do it to protect his patients. The 41-year-old has been a GP for eight years and says the system is at “breaking point”. He said, “We can't deliver for our patients. They’re struggling to get appointments. We don't want to take action but we’re being forced to protect our patients and staff.” As a partner in a practice in Newcastle, Dr Gorman is in charge of deciding what action to take next. That is because GPs are effectively independent businesses – so this is not a strike or campaign of industrial action in the traditional sense. The British Medical Association (BMA) has suggested GPs can pick-and-choose from a range of options. These include capping the number of patients that are seen each day, not doing tests and check-ups for hospitals, ignoring rationing guidelines which could result in a deluge of referrals for hospital care, and refusing data-sharing requests. NHS England has warned this work-to-rule action could push more people into seeking help from A&Es as well as having a wider impact on the system, such as delaying discharges from hospital. And patient watchdog Healthwatch England believes this could ultimately harm patients. “GP access is the most common issue we hear about," says chief executive Louise Ansari. “We’re worried the work-to-rule could make problems worse or even deter people from seeking help altogether. Any delay to care can have a huge impact on people’s physical and mental health.” Read full story Source: BBC News, 19 August 2024
  23. Content Article
    This rapid review by the Agency for Healthcare Research and Quality (AHRQ) summarises recent relevant literature on patient safety practices focused on engaging family caregivers with structured communication during care transitions. It assesses the effectiveness of these practices to improve safety during care transitions and provides information for clinicians, health system leaders and policymakers to better inform approaches to engaging family caregivers with structured communication during care transitions.
  24. Content Article
    This multinational study of 4,511,267 pregnancies in JAMA Neurology aimed to assess the associations between maternal epilepsy, antiseizure medication use during pregnancy and risks of severe maternal and perinatal morbidity and mortality. It found that: women with epilepsy were at considerably higher risk of severe maternal and perinatal outcomes and increased risk of death during pregnancy and postpartum. maternal epilepsy and maternal use of antiseizure medication were associated with increased maternal morbidity and perinatal mortality and morbidity. The authors identified an urgent need for enhanced counselling, perinatal support and access to specialised care for safe deliveries in all women with epilepsy.
  25. Content Article
    Patients’ lived experience is increasingly seen as a valid form of knowledge in healthcare. However, although it is often said to be a source of valuable information to complement the knowledge of healthcare professionals, it remains difficult for people within the system to understand and use the different forms of knowledge patients acquire through their experience. In addition, patient knowledge is often not seen as essential in co-building care plans or valued as an asset in building care relationships. This narrative review in the journal Social Theory & Health, aimed to: challenge the dominant model of knowledge in medicine and healthcare by making the various forms of patient knowledge more explicit and tangible. provide a better understanding of what experiential knowledge consists of by classifying the various forms of knowledge patient acquire, develop and use throughout their care journey. The authors classify six types of patient knowledge according to their source of learning: embodied, monitoring, navigation, medical, relational and cultural knowledge. They also identify three main sources of learning for patients: the self, the system and the community.

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