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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This case study looks at the experience of a mother whose baby boy collapsed and died 31 hours after being born at North Middlesex Hospital University NHS Trust. Due to his mother's history of group B Strep and exposure to meconium during the birth, the baby was put under neonatal review. However, although his mother repeatedly raised concerns about her son's condition, he was not checked over and her concerns dismissed. A review by the Healthcare Safety Investigation Branch (HSIB) into the baby's death found several issues with the care provided to both mother and son. It also raised serious concerns that the mother's ethnicity affected the care she received on the labour ward.
  2. Content Article
    Structured medication reviews (SMRs) were introduced to primary care teams in England in October 2020, with priority given to high-risk patients, including people diagnosed with frailty or living in care homes, people with complex polypharmacy, people taking medicines commonly associated with medication errors and anyone using potentially addictive pain management medicines. However, after NHS England removed financial incentives for Primary Care Networks to carry out SMRs in April 2023, pharmacists have been told to deprioritise SMRs. This article looks at work under way to make sure SMRs remain a priority as pharmacists aim to minimise inappropriate polypharmacy. This article is free to access, but you will need to sign up for a Pharmaceutical Journal account to view it.
  3. Content Article
    The Learning for Involvement website is dedicated to learning and development for public involvement in health and social care research— what’s it all about and how to do it well. Set up by the National Institute for Health and Care Research (NIHR), the website aims to provide public involvement information, resources and training together in one place. The content is suitable for people with different levels of experience in public involvement and includes resources on the following topics:Co-productionImpact and evaluationPaymentsGetting started: becoming involvedInclusive opportunitiesGetting started: involving people
  4. Content Article
    Neuromuscular blocking agents (NMBAs) are high-alert medications that require special handling and a robust process that prevents medication error and ultimately protects patients from harm. One patient at a large academic medical centre (AMC) was given vecuronium, a NMBA, instead of midazolam, and died as a result. The medical centre was tasked by the Centers for Medicare & Medicaid Services to make a list of actions to prevent a similar incident happening again. This study in Patient Safety analysed the medical centre's corrective action plan in comparison to the Institute for Safe Medication Practices’ hierarchy of effectiveness of risk-reduction strategies. The authors found that 76% of strategies in the plan were of low leverage, 16% were of medium leverage and 8% were of high leverage. They argue that the action plan should have included more system-based interventions, which include medium- or high-leverage strategies, rather than relying heavily on initiatives dependent on human action. Despite the lack of these systemic tools, CMS granted approval for the plan. The authors suggest that overlooking these systemic tools may amplify patient harm and negatively impact workforce satisfaction and efficiency. In addition, they highlight that the absence of a “just culture” also plays a role in patient harm. Recognising that medication errors in healthcare are usually attributed to human error highlights the importance of fostering a just culture that advocates for system accountability to enhance patient safety.
  5. Content Article
    This is the Professional Standards Authority's (PSA's) response to the UK Government's consultation on the White Paper: A pro-innovation approach to AI regulation. The PSA response highlights several concerns about the content of the White Paper, including: the potential for a policy gap in relation to professional regulation, particularly in light of the decision to regulate the use of AI rather than the technology itself lack of engagement with professional regulators or accredited registers in the healthcare sector on development of the proposals. the need for further work to understand the regulatory landscape for AI within the sectors of healthcare and social care. that the principles-based approach may place too much reliance on the capacity of multiple regulatory bodies to adapt and work together.
  6. Content Article
    Lesley Goodburn is Head of Public Involvement and Engagement at NICE and has worked in patient experience and public and patient involvement for the last 15 years. In this blog, Lesley describes the benefits of supporting people with lived experience to work in equal partnership to develop services and improve care. She explains how approaches such as digital storytelling that enable patients and families to share their experiences on their own terms can help organisations learn and improve their services. She also describes how she developed an impact and outcomes framework that aims to build the evidence base around the impact of storytelling.
  7. Content Article
    This randomised clinical trial aimed to find out whether crowdsourced feedback from members of the public is an effective educational intervention to improve resident doctors’ error disclosure communication skills. 146 second-year internal medicine and family medicine residents practiced disclosure with video simulation software. Crowdsourced laypeople then provided feedback on their responses. When residents who participated reviewed the feedback, it was associated with higher ratings of error disclosure skill, particularly for those without real-life experience of disclosing errors. This suggests that this kind of feedback may be an effective way for residency programs to address their requirement to prepare trainees for communicating with patients after medical harm.
  8. Content Article
    Older women are underrepresented in healthcare research, which has serious implications for the safety and effectiveness of the treatment they receive. In 2023, the US Government promised to address this problem through the White House Initiative on Women’s Health Research. This article examines some of the issues caused by lack of knowledge about how common health issues affect older women. It suggests priorities that should be included in the new initiative, including mental health, heart disease, brain health, cancer and bone health and frailty. More research in these areas will improve the safety and effectiveness of care and treatment for older women.
  9. Content Article
    Women in the United States experience a higher prevalence of many chronic conditions, including Alzheimer's disease, depression and osteoporosis, than men. They also experience female-specific conditions, such as endometriosis and pelvic floor disorders. A lack of research into both the biological and social factors that influence these conditions is a significant barrier to diagnosis, treatment and prevention efforts, contributing to poorer health outcomes for women and substantial costs to individuals and society. The US National Institutes of Health's Office of Research on Women's Health asked the National Academies of Sciences, Engineering and Medicine to host an expert committee to identify gaps in the science on chronic conditions that are specific to or predominantly impact women, or affect women differently, and propose a research agenda. This report presents the committee's conclusions and recommendations.
  10. Event
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    The Public Policy Projects Cancer Care conference 2024 will build on last year’s programme as well as looking at some of the emerging policies in cancer care in 2024 especially in light of political changes. We will host five panels that focus on some key aspects of cancer policy, highlight examples of best practice and better understand what strategies can be harnessed and implemented to improve patient outcomes. Throughout the day delegates will have time to network and also learn about how innovation, sometimes through industry partnerships, is impacting cancer care. Topics to be discussed Given our understanding of the risk factors for cancer, how can we address these and work towards prevention of cancer How can genomics be harnessed in cancer prevention without creating greater health inequalities? How can we work towards earlier diagnosis across cancer types using women’s cancers to explore this How can we address the backlogs in cancer pathways (through the lens of prostate cancer)? What strategies can be implemented that effectively reduce health inequalities in cancer? Given the advances in digital technologies, what are the opportunities for future screening? What innovations can be implemented now to speed up diagnostics? Can screening become equitable? Register for the conference
  11. Event
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    This conference will provide a focus on the pivotal issues concerning the future strategies of both the NHS Long Term Plan (LTP) and and integrated care systems (ICS) and will incorporate key elements of the 'Major Conditions Strategy' that is currently being developed. This major conditions strategy theme within the conference begins with one question: how should our approach to health and care delivery evolve to improve outcomes and better meet the needs of our population, which is becoming older and living with multimorbidity? With varying groups of conditions being explored in our plenaries and workshop sessions: cancers, cardiovascular disease (CVD) (including stroke and diabetes), mental ill health, and chronic respiratory disease. There are signs of positivity with exciting new technologies and sources of data that enable staff to better see and treat disease at an earlier stage. Our conference and its dedicated plenaries, evidence-based case studies and educational workshops will explore how to supercharge this agenda. Amongst our core themes will be the exploration of the potential of AI and technology to deliver digital transformations, and position the UK as a world leader in virtual health and social care. As such topics such as Virtual Wards, Remote Patient and Whole Patient Management systems will be at the forefront of certain plenaries. Also underpinning the conference's focus are the strong desires to tackle health disparities and promoting inclusion in health, as articulated through the NHS Core20PLUS5 framework, and detailed by senior host speakers on the day. The event is free for NHS staff, who can use code JBVIP100 when registering to remove all costs. Register for the conference
  12. Event
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    Standing for ‘For Patients, By Patients’, PxP 2024 is entirely led by an international team of patient and public partners and is a Patients Included™ event. Our purpose is to share resources, mentorship and community with patient partners and others involved in health research. Ultimately, our goal is partnering to make research stronger. This free, virtual event aims to bring you a wealth of knowledge, skills and resources on patient engagement in health research. Patient engagement in health research, also known as patient and public involvement (in the UK) or consumer involvement (in Australia). 'Patient engagement’ in health research is where patients are research team members. This is different from volunteering to be a research participant where you might help advance research or healthcare, but a research participant generally does not give input into the research study itself. Whatever language you prefer, we warmly welcome everyone to attend. PxP is a must-attend event for these two reasons: PxP is specifically For Patients. While there has been excellent progress in the available patient engagement resources, many of these are designed for other members of the research team. Although we welcome health researchers to join us at the event in September, our key priority will be patient partners and other people with lived experience. We are led entirely By Patients. Every topic and speaker on the PxP conference program has been chosen by our experienced international committee of patient partners. For those based in Europe, Africa and America, the dates are September 10-12, and for those in parts of Asia and Oceania the dates are September 11-13. Please note the timings for Day 3 are different from Days 1 and 2. This is because we would like as many people as possible from across the globe to have a chance to join us live. We would love you to join us! After the event, we will be hosting recordings on the PxP website which will be freely available. 2024 Steering Committee hope statement: To unite, inspire, and empower patients on their journey to health and wellness. May this summit be a beacon of hope fostering community, knowledge, and resilience as we navigate challenges together. Let us stand strong, advocate boldly, and transform research and healthcare for a brighter, healthier future. Work on the agenda is nearly complete, and we look forward to sharing the session and speaker details with you soon. Do not hesitate to reach out if you have any questions at [email protected]
  13. Event
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    The Experience and Partnerships Team at NHSE is hosting a Shine a Light on Co-production online event. This event aims to shine a light on the art of the possible in relation to co-produced improvements and demonstrate what can be achieved when we work together with people with lived experience. At each event people with lived and learnt experience share their experience of co-producing their improvement together. This will include the difference co-production made to them and their organisation, their top tips, what went well and the challenges they faced. Register for the event
  14. Event
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    This webinar from GovConnect will look at: Developing a successful Virtual Ward CUH Virtual Ward @ home (Cambridge University Hospitals) Challenges CUH faced and why they implemented Virtual Wards The journey so far and working with stakeholders What equipment is needed? Platform/technology selection Daily management: referral, on-boarding, care plan Performance and pathways Patient experience Challenges and obstacles Next steps Agenda Welcome and introduction with moderator Dr Iain Goodhart Developing a Virtual Ward @ home with Gemma Czech, Clinical Nurse Lead for Virtual Wards at Cambridge University Hospitals NHS Foundation Trust Outcomes, performance and next steps for CUH Virtual Ward @ home with Andy Bailey, Operations Manager Virtual Wards, Cambridge University Hospitals NHS Foundation Trust will cover how Interactive panel discussion Register for the webinar
  15. News Article
    A new vaccination programme aimed at protecting newborn babies and older adults against a dangerous respiratory disease is now being rolled out in Scotland. The Respiratory Syncytial Virus (RSV) immunisation programme begins on Monday morning, and will be offered in the other UK nations from September. RSV is common and highly infectious. It affects the breathing system and can cause severe illness in vulnerable groups, including infants and older people. It is the leading cause of emergency respiratory admissions to hospital in infants. In 2022-23, more than 1,500 infants under the age of one and more than 500 people aged 75 and over were hospitalised with RSV, according to Public Health Scotland. Across the UK as a whole it results in 25-30 infant deaths each year. While for many the symptoms are mild, the infection is easily spread and 90% of children will catch it within the first two years of their lives. The vaccine is being administered on the advice of the UK's Joint Committee on Vaccination and Immunisation (JCVI). Doses are being offered to women from 28 weeks into their pregnancies, to protect newborns, as well as those aged 75 and as a one-off catch up for those aged 75 to 79. Dr Sam Ghebrehewet, head of immunisation and vaccination at Public Health Scotland, said: "RSV can be very serious for those who are more vulnerable, such as newborns, infants and older adults. If you are eligible, getting vaccinated is the best and simplest thing you can do to protect yourself or your newborn baby from RSV." Read full story Source: BBC News, 12 August 2024
  16. Content Article
    US doctor Victoria Johnson recalls a medication error she made during one of her first shifts as a senior internal medicine resident. She describes the incident and how the compassionate response and honesty of her supervisor meant that she was able to forgive herself for her mistake. By telling her about a similar error he had made years before, he enabled Victoria to reflect on the toxic culture of perfection that had shaped her view of how she should be as a doctor. "In medicine, we don’t often talk about our errors. Yet in the wake of a serious error, the most healing conversations I’ve had have been with other physicians who have told me about their mistakes. Their vulnerability and empathy in sharing these difficult stories has proved to be the only true antidote to my shame." This article is free to access when you create a free online account with the New England Journal of Medicine.
  17. News Article
    About 400 million people worldwide have been afflicted with Long Covid, according to a new report by scientists and other researchers who have studied the condition. The team estimated that the economic cost—from factors like health care services and patients unable to return to work—is about $1 trillion worldwide each year, or about 1 percent of the global economy. The report, published Friday in the journal Nature Medicine, is an effort to summarize the knowledge about and effects of long Covid across the globe four years after it first emerged. It also aims to “provide a road map for policy and research priorities,” said one author, Dr. Ziyad Al-Aly, the chief of research and development at the V.A. St. Louis Health Care System and a clinical epidemiologist at Washington University in St. Louis. He wrote the paper with several other leading long Covid researchers and three leaders of the Patient-Led Research Collaborative, an organization formed by long Covid patients who are also professional researchers. Read full story (paywalled) Read the research study, Long COVID science, research and policy Source: New York Times, 9 August 2024
  18. News Article
    A debilitating virus originating in sloths and spread by midges has been reported for the first time in Europe, officials have confirmed. In June and July, 19 imported cases of the Oropouche virus were reported in Europe, according to the European Center for Disease Control. Twelve were reported in Spain, five in Italy, and two in Germany. The disease is mainly spread by insect bites - including mosquitos - and originates in pale-throated sloths, non-human primates and birds. There is currently no vaccine to treat the virus, which comes from the same family of diseases that includes Zika virus and Dengue Fever. Dr Danny Altmann, a professor of Immunology at Imperial College London, told The Telegraph: “We should definitely be worried. Things are changing and may become unstoppable.” Read full story Source: Independent, 11 August 2024
  19. News Article
    A doctor warned three years before the Nottingham attacks that Valdo Calocane's mental illness was so severe he could "end up killing someone." This was one of a series of missed opportunities over three years that could have prevented the killings, Calocane's mother and brother told BBC Panorama in their first interview. The doctor's warning appeared in a 300-page summary of medical records the family received only after Calocane was sentenced for the killings, which they have shared with Panorama. The chief executive of Nottinghamshire's NHS trust said he would do everything he could to stop such a tragedy happening again. Calocane was diagnosed with paranoid schizophrenia in 2020 and was sectioned four times in less than two years. In June 2023, he went on a rampage through the streets of Nottingham, killing students Barnaby Webber and Grace O’Malley-Kumar, both aged 19, with a knife as they returned from a night out, before stabbing to death Ian Coates, 65, near the school where he worked as a caretaker. Calocane then stole his van and crashed into three other people, inflicting serious injuries. The warning was given by one psychiatrist while the medical team reviewed Calocane on the ward and was set down in medical records held by Nottinghamshire NHS trust. Elias and Celeste, Calocane's brother and mother, said the mental health system was "broken" and led to a "tragedy that could have been prevented." Read full story Source: BBC news, 12 August 2024
  20. Content Article
    Humans are consuming more medications than ever before as a result of technological innovation transforming the treatment of ageing-related and chronic diseases. This article looks at the environmental impact of inappropriate prescribing in older people, including on carbon emissions, the pollution of rivers and disposal of waste to landfill. Its authors argue that tackling inappropriate polypharmacy in older people will both improve quality of life and mitigate the environmental effects of medicines. 
  21. Content Article
    Loeys-Dietz syndrome (LDS) is a genetic disorder affecting connective tissue, which supports, protects and gives structure to various tissues and organs. While it shares some characteristics with Marfan syndrome, LDS has distinct differences and presents unique challenges. LDS results from a variant in one of several genes, impacting multiple body systems and leading to potentially life-threatening complications. One of the most severe risks is aortic enlargement, which can cause an aneurysm or dissection. The aorta, the main blood vessel transporting blood from the heart, can become dangerously enlarged, increasing the risk of a tear that requires immediate medical attention.  This article tells the story of Sharon, a 53-year-old woman from Bristol, who died in December 2022. Her family now advocates for greater awareness of LDS to prevent similar tragedies. Sharon’s death, attributed to natural causes compounded by neglect, highlights systemic failures in promptly recognising and treating her aortic dissection. When she first went to hospital with severe chest pain, Sharon faced significant delays and inadequate care in the Emergency Department. The coroner’s inquest revealed that Sharon’s care was marred by a series of systemic and operational failures. She should have been assessed within an hour of arrival and transferred to a specialist centre for cardiothoracic surgery within four hours. Instead, she remained for over twelve hours in the Emergency Department, and a further six hours passed after a CT scan finally confirmed the need for emergency surgery. Tragically, these delays prevented Sharon receiving the life-saving intervention she required. Sharon’s family believes that the initial paramedic’s decision triggered a cascade of delays, ultimately costing her life. The subsequent care was inadequate, failing to provide the urgent cardiac specialist treatment necessary for her condition. The cumulative effect of these missteps highlights a critical need for improved pathways and awareness in treating LDS and similar aortic conditions.
  22. Content Article
    General practitioners (GPs) work in varied environment where diagnostic errors are common. Previous research indicates that combining independent diagnoses from different GPs can improve diagnostic accuracy in a range of settings. This study examined whether aggregating independent diagnoses can also improve diagnostic accuracy for GP decision making. In addition, it looked at the potential benefit of this approach in combination with a decision support system (DSS). The authors found that combining independent diagnoses may substantially improve a GP’s diagnostic accuracy and subsequent patient outcomes. This approach did, however, not improve accuracy in all patient cases. Therefore, future work should focus on determining the conditions in which collective intelligence is most beneficial in general practice. This year’s World Patient Safety Day on 17 September 2024 (WPSD 2024) is focused on the theme “Improving diagnosis for patient safety”. Find out more.
  23. Content Article
    Although most care occurs in the outpatient setting, knowledge of outpatient adverse events (AEs) remains limited. This study in Annals of Internal Medicine aimed to measure AEs in the outpatient setting through retrospective review of electronic health records (EHR). The results showed that outpatient harm was relatively common and often serious. Adverse drug events were most frequent and rates of harm were higher among older adults. The study demonstrates that Interventions to reduce outpatient harm are urgently needed.
  24. Content Article
    Falls are the most common cause of injury-related morbidity and mortality in older adults. This JAMA Network study aimed to systematically review evidence on the effectiveness and harms of fall prevention interventions in older adults living in the community. The study identified that multifactorial and exercise interventions were associated with reduced falls in multiple good-quality trials. Exercise demonstrated the most consistent statistically significant benefit across multiple fall-related outcomes.
  25. News Article
    The government has offered junior doctors a pay uplift worth around 20 per cent over two years to end their long-running industrial action. The British Medical Association’s junior doctors committee is set to recommended the offer to members who will vote on whether to accept and end their dispute, several reports said. HSJ understands the deal is worth a 22.3% cash terms pay increase over two years. Reports said it included a backdated pay rise of 4.05% for 2023-24, on top of the existing deal of 8.8-10.3% depending on role or level. Then for 2024-25, the offer is for a 6% rise, and an additional one-off consolidated £1,000 payment—equating to a 7-9% rise. If the deal is rejected by members, then industrial action could continue until at least September, when the junior doctors’ latest mandate is due to expire, days before the Labour party’s annual conference in Liverpool. The first strike was in March 2023. The Government has not yet confirmed details of the offer, nor how it will be funded. NHS funding assumptions for 2024-25 only cover uplifts of 2%. Read full story (paywalled) Source: HSJ, 29 July 2024

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