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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Fatigue is a perpetual risk in safety-critical industries. If that risk is not managed appropriately, it can result in a significant reduction in human performance, with associated impacts on safety. This paper from the Chartered Institute of Ergonomics & Human Factors (CIEHF) aims to present a roadmap for improving fatigue risk management in health and social care to improve patient safety and individual health workers' health and wellbeing. It makes a case for UK health and social care national bodies and organisations managing fatigue as a systemic risk.
  2. News Article
    NHS England is floating proposals to cut the elective waiting list by nearly 50 per cent to under 4 million over the next five years. HSJ understands this scenario is being discussed among system leaders as they brace themselves for the next government, whoever wins the general election, demanding a radical reduction in the waiting list. The list stood at 7.5 million as of the last official figures. The figure of just under 4 million is in part being targeted because this is the level NHS bosses estimate the list would need to be reduced to if the service is to return to meeting the standard that 92 per cent of patients referred are treated within 18 weeks, which has not been met since February 2016. Waiting list expert Rob Findlay estimated the required level would need to be closer to 3.5 million if the 92 per cent target is to be met. He told HSJ the list “would need to shrink to around 3.6 million before the statutory 18-week target became achievable again”. HSJ understands NHSE’s leadership believes a target of under 4 million could be credible—albeit likely dependent on targeted extra capacity, technology, resolution of strikes and on which other targets are set, especially around emergency waiting times. Progress could be accelerated by, for example, major outpatient reform to remove many appointments deemed unnecessary and use of technology to overhaul some pathways, officials believe. These could have a similar impact to the likes of faecal immunochemical testing, known as FIT, which is said to be playing a big role in reducing the cancer backlog. Read full story (paywalled) Source: HSJ, 26 April 2024
  3. News Article
    On Tuesday, the UK Covid inquiry which is sitting in Belfast for three weeks will start hearing from the most senior politicians and health advisors in Northern Ireland about why decisions were taken and by whom. This is module 2c of the inquiry, which is focusing on decision-making and political governance. This module will investigate Northern Ireland specifically and will include the initial response, central government decision making, and political and civil service performance. It will also probe whether Northern Ireland's political nuances had any affect on the effectiveness of the response. There were tensions between the political parties when senior Sinn Féin figures attended the funeral of ex-IRA leader Bobby Storey and when the DUP's Edwin Poots, then minister for Agriculture, Environment and Rural Affairs, said coronavirus was more common in nationalist areas. The hearings begin with opening statements and evidence from Covid-19 Bereaved Families and Disability Action. Core participants who have been named in advance include the former first ministers, Dame Arlene Foster and Paul Givan, and Michelle O'Neill, who was deputy first minster during the pandemic. Senior representatives from the departments of health, finance, the Executive Office, and the civil service will also be questioned. Read full story Source: BBC, 29 April 2024
  4. News Article
    The use of mixed-sex wards has gone “through the roof” after the number of men and women being put in beds next to each other soared to nearly its highest level in a decade. Official figures from NHS England show the government’s strict rules against doing so were broken nearly 5,000 times in February alone. NHS leaders voiced concerns over the high number of breaches and warned that care that was “unthinkable a decade ago is at risk of becoming the new normal”. Shadow health secretary Wes Streeting said patients were left feeling humiliated and at risk, adding: “The use of mixed-sex wards has gone through the roof under the Tories.” The government outlawed mixed wards in the NHS in 2010. Under the guidance, patients should not share wards overnight, share bathroom facilities or have to walk through areas occupied by patients of the opposite sex to get to the toilets. Despite promises more than a decade ago to eliminate mixed wards, The Independent found: 4,811 reported breaches in February, up from 3,789 last November Nurses warning “sky-high breaches” are the tip of the iceberg Evidence that patients are suffering sexual assaults while on mixed mental health wards Under the guidance, no mental health units should have mixed wards. However, earlier this year, The Independent revealed the practice is widespread, with more than 500 sexual assaults reported across almost half of the NHS mental health hospitals in England. Read full story Source: Independent, 28 April 2024
  5. Content Article
    A growing number of patients with eating disorders are reporting having treatment withdrawn by services, often without notice and without their consent. We spoke to eating disorder campaigner Hope Virgo about how pressures on services, enduring stigma around eating disorders and dangerous new narratives are leading to the practice of treatment withdrawal. Hope explains how this is affecting vulnerable patients and highlights that as the number of people developing eating disorders increases, the risks to patient safety will only get worse.
  6. News Article
    Sexual harassment levels in the NHS are “shameful”, with incidents happening all the time, one of the country’s top health chiefs has admitted. Dr Navina Evans, chief workforce officer at NHS England, urged leaders to act on shocking levels of sexual harassment, following exposes by The Independent. Asked about the one in eight workers who have reported unwanted sexual behaviour, she said: “It is shameful... I could tell you stories from my own experience from when I was a trainee right up to last year. Last year, the NHS published its “sexual safety charter” which requires organisations to commit to eliminating sexual harassment and assault among staff and patients. However, not all 240 NHS trusts have signed up to the charter yet, according to Dr Evans. She said: “It is really important that every organisation signs up.” The NHS staff survey this year found one in eight workers – around 58,000 – had reported experiencing unwanted sexual behaviour in the last 12 months, while one in 26 reported experiencing similar harassment from a work colleague. Read full story Source: Independent, 27 April 2024
  7. News Article
    Fears over patient safety have been raised after it was revealed that 600 jobs will be lost at hospitals in parts of Essex to save money. Mid and South Essex NHS Foundation Trust - which runs Southend, Basildon, Broomfield, St Peter's in Maldon and Braintree hospitals - is facing a £91m pound black hole in it's budget and said that "reducing headcount" would be necessary. The trust is one of the largest acute trusts in the country and employs 16,000 members of staff. It has a budget of around £1bn each year. Bosses said in a letter to staff that "all posts" must be reviewed, "including clinical roles". All current vacancies are being reviewed and no vacancies will be approved until that process is complete, they add. The news has been criticised by campaign groups and union bosses, who say that patients could be put at risk. UNISON Eastern regional organiser Sam Older said: "This vacancy freeze will ring alarm bells for already overworked staff. These 600 posts weren't created for the hell of it - they are there to provide healthcare to 1.2 million people in Essex. The trust was already struggling with rising demand. Slashing staff numbers, cancelling bank shifts and long waits to fill vacancies is only going to make this worse. And there's a clear risk that cutbacks will pose a threat to patient safety if staffing levels fall too low." Read full story Source: ITV, 27 April 2024
  8. Content Article
    This presentation looks in detail at Never Events, which it defines as serious, largely preventable patient safety incidents that should not occur if relevant preventative measures have been put in place. It sets out their history and development in the NHS in England, outlines different types of Never Events and considers how they can be tackled and prevented.
  9. Content Article
    This article reflects on the death of Wayne Jowett and the impact this had on how the NHS approaches patient safety. Wayne died after the cytotoxic drug vincristine, intended for intravenous injection, was instead injected into his spine. The circumstances around his death informed the subsequent development of Serious Reportable Events in the NHS, and later the Never Events Framework.
  10. Content Article
    This framework establishes a standardised approach to the annual appraisal of chairs, including ICB, NHS trust and foundation trust chairs. The appraisal should be a valuable and valued undertaking that provides an honest and objective assessment of a chair’s impact and effectiveness, while enabling potential support and development needs to be recognised and fully considered. The framework is aligned with the NHS Leadership Competency Framework and informed by multi-source feedback. It establishes a standard process, consisting of four key stages, to be applied to the annual appraisal of chairs.
  11. Content Article
    Disordered eating can affect anyone, but it can be confusing to understand and recognise it in our own personal experiences. This guide, published by East London NHS Foundation Trust, is a snapshot of how adults in East London have navigated those experiences of uncertainty while seeking support for disordered eating. For many of the contributors, preconceptions about what an eating disorder is (or isn’t) have previously acted as a barrier to seeking or receiving support. It also contains advice on how to seek support for disordered eating.
  12. Content Article
    Never Events are serious, largely preventable patient safety incidents that should not happen if the available preventative measures have been implemented by the healthcare provider. This document sets out the NHS approach to Never events and includes a list of recognised Never Events in 2012/13.
  13. Content Article
    This video provides an introduction to Sheffield Health and Social Care NHS Foundation Trust's (SHSCFT's) Patient and Carer Race Equality Framework (PCREF). The PCREF aims to help the Trust's staff and communities understand how to have sensitive conversations with patients and carers and to get better information from them. This will mean the Trust is more culturally aware and able to offer culturally appropriate care by understanding the barriers ethnic minority communities face in getting healthcare services for diagnosis and treatment.
  14. Content Article
    On 17 and 18 April 2024, government ministers, high-level representatives and health experts from all over the world gathered in Santiago, Chile for the Sixth Global Ministerial Summit on Patient Safety. In this long-read article, Patient Safety Learning’s Chief Executive Helen Hughes reflects on the key themes and issues discussed at the event.
  15. News Article
    An inquest jury has found there were “gross failings in care amounting to neglect” before a woman had a heart attack at a private mental health hospital due to complications from drinking excessive amounts of water. Lillian Lucas, 28, known as Lily to her family and friends, died in September 2022 after being found unresponsive in her room on Milton ward at the Cygnet hospital in Kewstoke, near Weston-super-Mare, where she had been an inpatient since June. An inquest jury at Avon coroner’s court found on Wednesday that opportunities were missed by staff to render care that would have prevented Lucas’s death, including a failure to monitor her worsening condition and inadequate response to her deterioration. On 8 September 2022 she was found unresponsive in her room after drinking excessive amounts of water and transferred to Bristol Royal Infirmary (BRI), the jury heard. She died the following day. Postmortem examinations found she died of a heart attack and the impact of psychogenic polydipsia, when due to a mental disorder a person experiences an uncontrollable urge to drink water. The jury concluded on Wednesday that there were “gross failings in her care amounting to neglect”. In the record of the inquest, the jury said the Milton ward was “understaffed at a level deemed to be unsafe”. Read full story Source: Guardian, 24 April 2024
  16. News Article
    An NIHR and UK Research and Innovation (UKRI) funded study has revealed that Long Covid leads to ongoing inflammation which can be detected in blood. This suggests that existing drugs which help treat conditions that affect the body’s immune system could be helpful in treating Long Covid, and should be investigated in future clinical trials. The study, which has been published in Nature Immunology, is from two collaborative UK-wide consortia, PHOSP-COVID and ISARIC-4C. These involve scientists and clinicians from universities across the UK, including Imperial College London and the Universities of Leicester, Edinburgh and Liverpool, among others. The research compared 426 people who were experiencing symptoms consistent with Long Covid with 233 people who were also hospitalised for Covid-19 but had fully recovered. The researchers took samples of blood plasma and measured a total of 368 proteins known to be involved in inflammation and immune system modulation. They found that, relative to patients who had fully recovered, those with Long Covid showed a pattern of immune system activation indicating inflammation of myeloid cells and activation of a family of immune system proteins called the complement system. Read full story Source: NIHR, 11 April 2024
  17. Content Article
    The debate about fairness of artificial intelligence (AI) in health care is gaining momentum. At present, the focus of the debate is on identifying unfair outcomes resulting from biased algorithmic decision making. This article in The Lancet Digital Health looks at the ethical principles guiding outcome fairness in AI algorithms.
  18. Content Article
    This Office for National Statistics (ONS) report provides in-depth analysis of Winter Coronavirus Infection Study (Winter CIS) data looking at trends in self-reported symptoms of Covid-19 including ongoing symptoms and associated risk factors. Winter CIS was a joint study with the UK Health Security Agency (UKHSA), carried out between November 2023 and March 2024 for England and Scotland. The study was structured as a longitudinal panel survey, with each participant sent a questionnaire and asked to take a lateral flow device test every four weeks for the detection of Covid-19.
  19. News Article
    The Royal Pharmaceutical Society (RPS) has published updated professional standards to support pharmacists, pharmacy technicians and pharmacy teams in responding to patient safety incidents. Created in collaboration with the Association of Pharmacy Technicians UK (APTUK) and the Pharmacy Forum Northern Ireland (PFNI), the Patient safety professional standards: responding to patient safety incidents are designed to support pharmacy professionals to meet regulatory standards. The standards, published on 24 April 2024, reflect new legislation and updated guidance from the General Pharmaceutical Council and NHS England, replacing the previous standards published in 2016. They also provide a framework for reflecting, reporting and recording incidents, and sharing learning, taking action and reviewing and evaluating incidents as part of a patient safety culture. Read full story Source: The Pharmaceutical Journal, 24 April 2024
  20. Content Article
    Sheffield Health and Social Care NHS Foundation Trust's (SHSCFT's) Patient and Carer Race Equality Framework (PCREF) aims to help the Trust's staff and communities understand how to have sensitive conversations with patients and carers and to get better information from them. This will mean the Trust is more culturally aware and able to offer culturally appropriate care by understanding the barriers ethnic minority communities face in getting healthcare services for diagnosis and treatment. This video was produced by SHSCFT to help staff, service users and their families understand the importance of sharing information around their ethnicity and protected characteristics.
  21. Content Article
    These patient safety professional standards aim to support pharmacists when responding to patient safety incidents. They describe good practice and provide a broad framework for continually improving services, shaping future services and roles and delivering high-quality care across all settings and sectors. They have been developed by the Royal Pharmaceutical Society (RPS), Association of Pharmacy Technicians UK and Pharmacy Forum NI, with the support of an expert steering group and public consultation. Pharmacists, pharmacist prescribers, pharmacy technicians and the wider pharmacy team across the United Kingdom will find these standards useful. They may also be of interest to the public, to people who use pharmacy and healthcare services, other healthcare professionals working with pharmacy teams, regulators and commissioners of pharmacy services.
  22. Event
    until
    The future of health and care lies at the intersection of prevention and precision. It’s a paradigm shift that requires vision, leadership, change management and the critical need to be radical. At Radical Health Festival Helsinki 2024, we’re not just thinking about the future of healthcare; we’re redefining it. Imagine a world where health is a lifelong journey, where risks are identified before they turn into crises, and care is personalised for every citizen. Is this just a pipe dream? No, it’s the radical shift we need now more than ever! This year, we deep dive into the intersection of prevention and precision. It’s a bold move and a paradigm shift requiring bold leadership. But it´s the only way forward. The 2024 programme explores the three pillars and key questions that will enable this deployment at scale: PEOPLE: Can we shift our focus from technology to people and place humans at the heart of digital transformation efforts? INNOVATION: Can we re-think innovation frameworks to accelerate the adoption and integration of cutting-edge technologies in clinical pathways? DATA: How do we turn data into insights for prevention, precision, and equity? We may not have all the answers. But Radical Health Festival Helsinki is where radical ideas take flight. Find out more about the festival
  23. News Article
    Use of antipsychotic medications in patients with dementia is linked with a much wider range of serious harms than previously thought, say UK researchers. Although there have been safety warnings on use of the antipsychotics from regulators about increased risk of stroke and death, a large study has now found increased risks for pneumonia, venous thromboembolism, heart attack, heart failure, fracture, and acute kidney injury. Reporting the findings in the BMJ, researchers from the University of Manchester said it underscores the need for increased caution when prescribing. The analysis showed that antipsychotic use was associated with increased risks for all outcomes looked at with the exception of ventricular arrhythmia. Over the first six months of treatment, it was estimated that antipsychotic use was linked with one additional case of pneumonia for every nine patients treated, and one additional heart attack for every 167 patients treated. Professor Charles Marshall, professor of clinical neurology at Queen Mary University of London, said the study findings should prompt renewed efforts to reduce the prescribing of antipsychotics to people living with dementia. "There are rare circumstances where antipsychotics are genuinely required, and the benefits outweigh these risks, but for the majority of patients with behavioural symptoms that might lead to them being prescribed anti-psychotics, we should be focussing on much safer behavioural management approaches." Read full story Source: Pulse, 24 April 2024
  24. News Article
    The Biden administration set a first-ever minimum staffing rule for nursing homes Monday, making good on the president’s promise more than two years ago to seek improvements in care for the nation’s 1.2 million nursing home residents. The final rule, proposed in September, requires a registered nurse to be on-site in every skilled nursing facility for 24 hours a day, seven days a week. It mandates enough staff to provide every resident with at least 3.48 hours of care each day. And it beefs up rules for assessing the care needs of every resident, which will boost staff numbers above the minimum to care for sicker residents. For a facility with 100 residents, it translates to a minimum of two or three registered nurses and at least 10 or 11 nurse aides per shift, as well as two additional staffers who could be nurses or aides per shift, according to the administration’s interpretation of its new formula. Set to phase in over the next few years, the mandate will replace the current vague standard that gives operators wide latitude on how to staff their facilities. While the administration has said the rule will improve care, industry lobbyists have said it’s unworkable, with staffing goals that will be impossible to achieve because of a shortage of workers. The administration received 47,000 public comments on the rule since it was proposed last September. They included observations of people lying in their own filth for hours, not being fed appropriately and being left on the floor too long after falling, Secretary of Health and Human Services Xavier Becerra said in an interview Monday. Read full story Source: Washington Post, 22 April 2024
  25. News Article
    Female survivors of breast cancer living in the most deprived areas have a 35% higher risk of developing second, unrelated cancers, compared with those from the most affluent areas, research shows. Breast cancer is the most commonly diagnosed cancer in the UK, with about 56,000 people being told they have it each year. Improved diagnosis and treatments mean that five-year survival rates are now 86% in England. People who survive breast cancer have a greater likelihood of second primary (unrelated) cancer, but until now the exact risk has not been clear. A team of researchers led by the University of Cambridge analysed NHS data from almost 600,000 patients in England and found, compared with the general female population, women who had survived breast cancer had an increased risk of developing 12 other primary cancers. Compared with the most affluent, the least well-off female survivors of breast cancer had a 166% greater chance of developing lung cancer, a 78% higher risk of stomach cancer, more than 50% increased risk of bladder and oesophagus cancers, 48% higher risk of head and neck cancer and 43% increased risk of kidney cancer. Read full story Source: Guardian, 24 April 2024
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