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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    In this report the Parliamentary and Health Service Ombudsman (PHSO) looks at patient safety concerns relating to the care and discharge of mental health patients. Its findings are based on the analysis of more than 100 complaints that the Ombudsman has investigated between April 2020 and September 2023 where it found failings in care that involved mental health care.
  2. News Article
    The NHS is in such a dire state the next government should declare it a national emergency, experts are warning, as it emerged that record numbers of patients are being denied timely cancer treatment. It is facing an “existential threat” because of years of underinvestment, serious staff shortages and the demands of the ageing population, according to a group of leading doctors and NHS leaders. Whoever wins power after the general election will have to “relaunch” the health service and ask the public to do what they can to help save it and preserve its founding principles, they say. The call, by a commission of experts assembled by the BMJ medical journal, comes as new figures show that since 2020 more than 200,000 people in England have not received potentially life-saving surgery, chemotherapy or radiotherapy within the NHS’s supposed maximum 62-day wait. Professor Pat Price, a leading NHS oncologist who helped analyse NHS cancer care data, said that the UK was facing “the deepest cancer crisis” of her 30-year career treating cancer patients. The acute concern about the NHS’s ability to cope with the rising tide of illness deepened last night when A&E doctors claimed that a government plan launched a year ago to relieve the strain on overcrowded emergency departments had made no difference. A&E remains in “permacrisis” while care in units is “as unsafe, or more unsafe, than at this time last year”, despite Rishi Sunak hailing his “ambitious and credible plan to fix it”. Although 5,000 more hospital beds have been created, the “half-baked” plan has “made little real difference to the experience of patients and the working conditions of health care professionals”, said Dr Ian Higginson, the vice-president of the Royal College of Emergency Medicine. Read full story Source: Guardian, 31 January 2024
  3. News Article
    Mental health services are failing to keep patients safe from suicide and harm after leaving hospital, the Parliamentary and Health Service Ombudsman (PHSO) has warned. It also identified failings around planning and communication when patients are discharged, and has urged the Government to strengthen the Mental Health Act. The warning comes after the Department for Health and Social Care was forced to announce a Care Quality Commission (CQC) rapid review into mental health services in Nottingham following the killings of students Grace O’Malley-Kumar and Barnaby Webber, both 19, and school caretaker Ian Coates, 65, in June last year, by Valdo Calocane. Knifeman Calocane had paranoid schizophrenia and had been a regular patient of Highbury Hospital with mental health problems. In a report last week, The Independent revealed separate investigations into Highbury Hospital which have led to the suspension of more than 30 staff over allegations of falsifying records and harming patients. The latest report by the Parliamentary and Health Service Ombudsman (PHSO), following a report in 2018, looked at more than 100 complaints between 2020 and 2023 where it had identified failings in mental health care. Lucy Schonegevel, director of policy and practice at the charity Rethink Mental Illness, said: “Someone being discharged from a mental health service, potentially into unsafe housing, financial insecurity or distanced from family and friends, is likely to face the prospect with anxiety and a sense of dread rather than positivity. Mistakes or oversights during this process can have devastating consequences. This report puts a welcome spotlight on how services can improve the support they offer people going through the transition back into the community, by improving communication and the ways in which different teams work together to provide essential care.” Read full story Read PHSO report Discharge from mental health care: making it safe and patient-centred (PHSO, 1 February 2024) Source: Independent (1 February 2024)
  4. News Article
    A major review into a mental health unit abuse scandal has found a catalogue of failings, including repeated missed opportunities to act on concerns, and a board “disconnected” from the realities faced by patients and staff. The independent review into failings at Greater Manchester Mental Health Foundation Trust was published today, commissioned after BBC Panorama revealed a “toxic culture of humiliation, verbal abuse and bullying” at Edenfield Centre in Prestwich in September 2022. The trust’s then chair, Rupert Nichols, resigned in November 2022, and CEO Neil Thwaite stepped down in spring last year. Review chair Professor Oliver Shanley, a former mental health trust CEO and chief nurse, describes in his report how the trust’s culture and leaders’ “insufficient curiosity” contributed to the “invisibility” of the deterioration in care quality. He says its board was focused on “expansion, reputation and meeting operational targets”. Read full story (paywalled) Read the report of the Independent Review into Greater Manchester Mental Health NHS Foundation Trust Source: HSJ, 31 January 2024
  5. Content Article
    With a number of large-scale clinical trials underway and researchers on the hunt for new therapies, Long Covid scientists are hopeful that this is the year patients will finally see improvements in treating their symptoms. This article in Medscape makes five research-based predictions that could happen in 2024. They provide promising signs of progress in treating a debilitating and frustrating disease. The predictions are: We'll gain a better understanding of each Long Covid phenotype Monoclonal antibodies may change the game Paxlovid could prove effective for Long Covid Anti-inflammatories like metformin could prove useful Serotonin levels may be keys to unlocking Long Covid
  6. Content Article
    This study in the British Journal of General Practice aimed to assess the risk of poor respiratory outcomes for people with resolved asthma compared to those with active asthma and people without asthma. The authors used three retrospective cohorts of around 16,000 patients each, in the following groups: Active asthma cohort (patients with an asthma-specific diagnostic code at any point in their GP record, and >1 asthma medication prescription). Resolved asthma cohort (patients with >1 resolved asthma code, followed from date of first resolved asthma during the study period to the earliest data of an asthma prescription, the end of the study period, date of transfer out of practice or death). Non-asthma cohort (population-based patients without active or resolved asthma or chronic obstructive pulmonary disease). The results showed that compared to the active asthma cohort, the resolved asthma cohort had fewer GP consultations for asthma exacerbations and fewer asthma hospital admissions. However, compared with non-asthma patients, resolved asthma patients had more GP consultations, greater rates of respiratory tract infections and higher rates of antibiotic use. The authors highlighted a lack of guidance around care pathways for patients with a record of resolved asthma. They concluded that patients with resolved asthma may need a more comprehensive respiratory assessment if they present with symptoms of lower respiratory tract infection, in order to assess symptom burden, airway obstruction and the potential value of inhaled treatment.
  7. Content Article
    In November 2023, the UK hosted the first global summit on artificial intelligence (AI) safety at Bletchley Park, the country house and estate in southern England that was home to the team that deciphered the Enigma code. 150 or so representatives from national governments, industry, academia and civil society attended and the focus was on frontier AI—technologies on the cutting edge and beyond. In this Lancet article, Talha Burki looks at the implications of AI for healthcare in the UK and how it may be used in medical devices and service provision. The piece highlights the risks in terms of regulation and accountability that are inherent in the use of AI.
  8. Content Article
    Sarah Rainey talks to Olivia Djouadi about her experience of type 1 diabetes with disordered eating (T1DE), which is thought to affect up to 40% of women and 15% of men with type 1 diabetes. People with T1DE, sometimes also called diabulimia, limit their insulin intake to control their weight, which can have life-threatening consequences. Olivia describes how the stress of living with type 1 contributed to her developing T1DE, and how when she finally received treatment and support in her 30s, she was able to deal with her disordered eating and see her health and wellbeing improve.
  9. Content Article
    Emergence delirium is a temporary but potentially dangerous condition that can occur when a patient awakens after a procedure. In this video, staff at the VA Pittsburgh Healthcare System (VAPHS) share how they implemented a perioperative intervention to reduce the risk of patient and staff harm.
  10. Content Article
    This article in Anaesthesia Critical Care & Pain Medicine aims to provide guidelines to define the place of human factors in the management of critical situations in anaesthesia and critical care. The authors aimed to formulate recommendations according to the GRADE® (Grading of Recommendations Assessment, Development and Evaluation) methodology for four different fields:communicationorganisationworking environmenttrainingThe guidelines produced include a set of recommendations to guide human factors in critical situations.
  11. Content Article
    Doctors At Work is a series of video podcasts hosted by Dr Mat Daniel. In this episode, Dr Gordon Caldwell shares his experiences of managing and preventing adverse events. He stresses the importance of creating a culture that encourages everyone to speak up. His top tips for preventing errors is to create systems, checklists and routines that ensure a focus on all aspects of care not just the obvious and urgent.
  12. Content Article
    Antibiotic resistance is an increasing problem in healthcare, especially in nursing homes where up to 75% of antibiotics are prescribed inappropriately. This series of webinars from the Pennsylvania Patient Safety Authority covers various aspects of antibiotic stewardship including: Types of antimicrobials Why antibiotic stewardship and who should be at the table Antimicrobial usage Mechanisms of antimicrobial resistance Antibiograms Antimicrobial baseline data Developing an antimicrobial stewardship plan Antimicrobial usage data
  13. Content Article
    This document outlines the concept and content of the World Health Organization (WHO) people-centred approach to addressing antimicrobial resistance (AMR) in healthcare. It aims to address the challenges and barriers people face when accessing health services to prevent, diagnose and treat drug-resistant infections. It puts people and their needs at the centre of the AMR response and guides policy-makers in taking actions to mitigate AMR.
  14. Content Article
    The first UK geriatric oncology service at a tertiary cancer centre was established at the Royal Marsden Hospital in London. Its purpose is to conduct comprehensive geriatric assessments of patients with cancer on order to make referrals to multidisciplinary care. This descriptive study aimed to track its progress. It found that the service made a median of three referrals for each patient, most commonly to physiotherapy and occupational therapy. The frequency of referrals indicates that there is a high level of unmet need in older patients with cancer.
  15. Content Article
    This resource library has been created by Health Innovation West of England to provide support materials in one location for people living with pain and professionals supporting people living with pain.
  16. Content Article
    This training tracker from the Patient Experience Library helps you find courses on patient experience and patient/public involvement hosted by a range of external organisations. Each listing contains details on how to book places and contact the course providers.
  17. Content Article
    This statement from NHS England outlines how NHS organisations should collect and present data on health inequalities and explains the powers available to them to collect such data. Integrated care boards, trusts and foundation trusts should use the statement to identify key information on health inequalities and set out how they have responded to it in annual reports. The statement has been produced according to NHS England's duty under section 13SA of the National Health Service Act 2006.
  18. Content Article
    People taking methotrexate (for inflammatory conditions such as rheumatoid arthritis) have regular blood tests to check for certain side effects. Researchers have developed a tool to predict the likelihood of them discontinuing methotrexate due to these side effects, which could in future lead to less frequent testing for most people (68%) on methotrexate. The tool uses information routinely collected by GPs. The study found that it could predict people’s risk of discontinuing methotrexate because of side effects. It was accurate for most people across different ages, inflammatory conditions, methotrexate doses and routes of administration. The researchers say the tool could in future be used by GPs to identify people who need more or less frequent blood tests. This article refers to the original research study Risk stratified monitoring for methotrexate toxicity in immune mediated inflammatory diseases: prognostic model development and validation using primary care data from the UK
  19. Event
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    This popular training day covers the must-dos and the grey areas around the statutory Duty of Candour, with a strong emphasis on going beyond mere compliance and delivering the duty of candour in a meaningful way for patients and families and for the staff involved and the organisation. It has been updated to directly support the successful implementation of the PSIRF guidance and the ‘Harmed Patient Pathway’. The training is delivered by Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. Prices: £245 (plus vat) per person. Discounted rate for bookings of 3 or more: £220 (plus vat) per person AvMA is offering a 10% discount for delegates referred via the hub. Use code: DoC-Hub-10 Register for the training Training can also be delivered in-house at your organisation, either in person or online. Please enquire for details by emailing paulas@avma.org.uk
  20. Content Article
    Connections are critical junctures and points of access along intravenous (IV) lines. Microorganisms may colonise these connections, potentially leading to catheter-related bloodstream infections (CRBSIs). For patients, CRBSIs are a significant cause of morbidity and death, and for healthcare facilities these infectious complications lead to unnecessary costs. Safe connections may help reduce the risk of needlestick injuries for healthcare professionals (HCPs) and the occurrence of CRBSIs for patients. In this webinar recording, Nancy Trick, Registered Nurse and Adjunct Instructor at Perdue Global University in West Lafayette, USA, discusses CRBSIs and presents solutions to help prevent them. After watching this webinar, you should be able to: describe open versus closed infusion systems in VAM. briefly discuss the clinical risks of open infusion systems. discuss clinical practice change. consider how evidence-based standards of practice recommend using closed IV access/needleless connectors.
  21. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Benjamin talks about why we need a radical shift in how we view and treat people with chronic pain and how over-investigation and over-treatment compromise patient safety. He also talks about the power of communal singing for people with long-term conditions and what wild swimming has taught him about supporting people living with chronic pain.
  22. Content Article
    Left-handedness was historically considered a disability and a social stigma, and teachers would make efforts to suppress it in their students. Little data are available on the impact of left-handedness on surgical training and this report aimed to review available data on this subject. The review revealed 19 studies on the subject of left-handedness and surgical training. Key findings include: Left-handedness produced anxiety in residents and their trainers. There was a lack of mentoring on laterality. Surgical instruments, both conventional and laparoscopic, are not adapted to left-handed use and require ambilaterality training from the resident. There is significant pressure to change hand laterality during training. Left-handedness might present an advantage in operations involving situs inversus or left lower limb operations.
  23. Content Article
    This report outlines the results of a survey carried out by The Institute of Health Visiting (iHV)—the largest UK survey of frontline health visitors working with families with babies and young children across the UK. Poverty was the cause of greatest concern to health visitors, with 93% reporting an increase in the number of families affected by poverty in the last 12 months. Other key findings included: 89% of health visitors reported an increase in the use of food banks 78% an increase in perinatal mental illness 69% an increase in domestic abuse 63% an increase in homelessness and asylum seekers 50% an increase in families skipping meals as a result of the cost-of-living crisis.
  24. Content Article
    In this interview for inews, Professor Ted Baker, Chair of the new Health Services Safety Investigations Body (HSSIB), talks about the role of HSSIB in identifying system-wide safety issues in the NHS. He discusses why we need new approaches to tackling patient safety problems and outlines the importance of considering how the wider system leads to human error. He also talks about the impact of bullying on NHS staff, describing his own experiences as a junior doctor, which nearly led him to give up his career. He also describes the vital role of whistleblowers in making changes that genuinely improve patient safety, highlighting the problems currently facing staff who speak up for patient safety.
  25. Content Article
    Boards and leaders of healthcare organisations are legally responsible for the performance of their organisation and must take definitive responsibility for improvements, successful delivery and failures in the quality of care. Board effectiveness relies on the ways in which board members translate their knowledge and information into quality and safety plans with measurable goals, maintain oversight on progress towards these goals and hold the chief executive accountable for these goals. This resource by the Canadian Patient Safety Institute lists tools available to boards and board members to allow them to understand their legislative responsibilities for quality and safety, conduct self-evaluation and understand the competencies needed to lead on quality and patient safety.
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