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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This NHS dentistry and oral health update has a special focus on patient safety. It includes an introduction by newly appointed Interim Chief Dental Officer (CDO) for England, Jason Wong and covers the following topics: Quality and safety in dental care  Contributing to patient safety learning Using the Learning from Patient Safety Events (LFPSE) service Patient safety incidents and harm Patient Safety Incident Response Framework (PSIRF) Spotlight on Project Sphere Regulatory support Clinical leadership in patient safety
  2. Content Article
    In January 2023, NHS England’s Delivery plan for recovering urgent and emergency services committed the health service to ease the growing pressure on hospitals by scaling up the use of ‘virtual wards’. Also known as ‘hospital at home’, virtual wards allow people to receive treatment and care where they live, rather than as a hospital inpatient, while still being in regular contact with health professionals. This article by The Health Foundation looks at how NHS staff and the UK public feel about the use of virtual wards, based on the results of a survey of 7,100 members of the public and 1,251 NHS staff members. The survey aimed to assess how supportive these groups are of virtual wards and what they think is important for making sure they work well.
  3. Content Article
    This toolkit aims to help GP practices set up and run effective Patient Participation Groups (PPGs). It includes resources to help set up and develop PPGs, as well as to help PPGs think creatively about patient involvement. The toolkit covers:Guide to setting up a PPGVirtual groupsIncreasing membershipWhat can Healthwatch do to help?
  4. Content Article
    In this blog for the Royal College of Physicians, patient Hayley Hall argues that engaging members of the public in digital transformation will help ensure that changes made bring real benefits not just to the health service also but to patients, carers, family members and communities.
  5. Content Article
    This series of training programmes was collaboratively developed by eating disorder charity Beat, Health Education England and NHSE. It was developed in response to the 2017 PHSO investigation into avoidable deaths from eating disorders, as outlined in recommendations from the report Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients. It is designed to ensure that healthcare staff are trained to understand, identify and respond appropriately when faced with a patient with a possible eating disorder. It includes sessions relevant for different healthcare professionals and includes: Medical students and foundation doctors programme Nursing workforce sessions GP and Primary care workforce sessions Medical Monitoring in eating disorders Understanding Eating Disorders Webinar resource for dietitians, oral health teams and community pharmacy teams
  6. Content Article
    This guidance for users of the new Learn from Patient Safety Events (LFPSE) service provides context and guidance on selection of appropriate categories when recording incidents. It focuses on which Event Type is appropriate for different circumstances, and how to select the most appropriate options for the Levels of Harm categorisation required within Patient Safety Incidents. It covers the following topics: Definitions – event types Definitions – harm grading When are harm grading fields mandatory? Recording guidance questions and answers
  7. Content Article
    This report by the National Audit of Dementia (NAD) presents the results of the fifth round of audit data. For the first time, the audit has been undertaken prospectively, which will enable hospitals to take earlier action to improve patient care and experience. However, this has demonstrated that many hospitals still have no ready mechanism to identify people with dementia once admitted. One notable improvement is delirium screening (dementia is the biggest risk factor for developing delirium). Screening for delirium has improved from 58% in round 4 to 87% in the current audit. In addition, a high number of pain assessments are also being undertaken within 24 hours of admission (85%). Although encouraging, the report highlights that 61% of these assessments were based only on a question about pain—an approach that can be unreliable in patients with dementia. While this report acknowledges that our health services have experienced an extraordinarily difficult and challenging time, it does shine a light on a need for more training. It states that is encouraging that many staff have received Tier 1 dementia training (median 86%), but suggests that a much higher proportion of ward-based patient facing staff should have received Tier 2 dementia training (median 45%). It found that only 58% of hospitals are able to report the proportion of staff who have received training. As such, the report recommends that any member of staff involved in the direct care of people with dementia should have Tier 2 training, and this training should be recorded to provide assurance to the public and regulators.
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    This event from Five X More is all about celebrating and empowering women's health at every stage of life, from pre-teen to pregnancy and beyond. It includes a line up of esteemed guest speakers who are experts in their fields, ready to share insights, knowledge and inspiration that you won't want to miss. Join Five X More for a day filled with engaging discussions, interactive sessions, and valuable takeaways that will uplift and enhance your well-being. From menstrual health to maternal care and menopause, the event will cover a wide range of topics that matter to you. Find out more and get tickets
  9. News Article
    Women who struggle with their mental health have an almost 50% higher risk of preterm births, according to the biggest study of its kind. The research, published on Tuesday in the Lancet Psychiatry, examined data from more than 2m pregnancies in England and found about one in 10 women who had used mental health services had a preterm birth, compared with one in 15 who did not. The study also found a clear link between the severity of previous mental health difficulties and adverse outcomes at birth. Women who had been admitted to psychiatric hospital were almost twice as likely to have a preterm birth compared with women who had no previous contact with mental health services. And women with history of mental health difficulties faced a higher risk of giving birth to a baby that was small for its gestational age (75 per 1,000 births compared with 56 per 1,000 births). The study recommends that when pregnant women are first assessed by doctors and midwives they should be sensitively questioned in detail about their mental health. One of the reports authors, Louise Howard, professor emerita in women’s mental health at King’s College London, said such screening would help identify “clear red flags for a possible adverse outcome”. Read full story Source: Guardian, 14 August 2023
  10. News Article
    Ministers have named the 30 trusts which will receive a share of a £250m fund to increase urgent and emergency care capacity. The £250m pot is part of commitments made earlier this year in the NHS urgent and emergency care recovery plan, which pledged £1bn for 2023-24 to increase capacity (see full list of schemes in table below). Trust leaders welcomed the funding but raised concerns about the announcement, stating that much of the extra capacity would not be in place until January and also raised questions about how extra beds would be staffed. The funding will go towards creating 900 “new” hospital beds ahead of winter, which includes more than 60 intermediate care beds, improving assessment spaces and cubicles in accident and emergency departments, and developing or expanding urgent treatment centres and same day emergency care services. NHS England expected the “majority” of these schemes will be completed by January, the announcement said. This article contains a list of the schemes and how much funding each will receive. Read full story (paywalled) Source: HSJ, 15 August 2023
  11. News Article
    Vanderbilt University Medical Center is facing a federal civil rights investigation after turning the medical records of transgender patients over to Tennessee’s attorney general, hospital officials have confirmed. The U.S. Department of Health and Human Services’ investigation comes just weeks after two patients sued VUMC for releasing their records to Attorney General Jonathan Skrmetti late last year. “We have been contacted by and are working with the Office of Civil Rights,” spokesperson John Howser said in a statement late Thursday. “We have no further comment since this is an ongoing investigation.” VUMC has come under fire for waiting months before telling patients in June that their medical information was shared late last year, acting only after the existence of the requests emerged as evidence in another court case. The news sparked alarm for many families living in the ruby red state where GOP lawmakers have sought to ban gender-affirming care for transgender youth and limit LGBTQ rights. The patients suing over the release of their information say VUMC should have removed personally identifying information before turning over the records because the hospital was aware of Tennessee authorities’ hostile attitude toward the rights of transgender people. Many of the patients who had their private medical information shared with Skrmetti’s office are state workers, or their adult children or spouses; others are on TennCare, the state’s Medicaid plan. Some were not even patients at VUMC’s clinic that provides transgender care. “The more we learn about the breadth of the deeply personal information that VUMC disclosed, the more horrified we are,” said attorney Tricia Herzfeld, who is representing the patients. “Our clients are encouraged that the federal government is looking into what happened here.” Read full story Source: NBC News, 10 August 2023
  12. News Article
    A new symptom of long Covid has been revealed by scientists at the University of Leeds. Though most people who contract Covid recover within a few days or weeks of experiencing initial symptoms, some people can experience longer, more persistent symptoms – termed Long Covid or post Covid-19 syndrome by the NHS. Until now, the most commonly identified symptoms have included extreme tiredness, loss of smell, muscle aches and shortness of breath. Others include memory problems, chest pain, insomnia, heart palpitations, dizziness, joint pain, tinnitus and depression and anxiety. Now, a new study has revealed a previously unidentified symptom of long Covid. Published in The Lancet medical journal, the research detailed a new symptom of the condition after a 33-year-old man was referred to the specialists’ clinic. The patient had a six-month history of what the authors describe as a “rapid purple discolouration” on his legs. When standing, he remarked that they would feel progressively heavier and become “tingly, itchy and dusky” in colour. He added that a rash would occasionally appear on his feet, but that the mysterious symptoms would disappear when laying down. The disorder is known as acrocyanosis or persistent and extreme blue or cyanotic discolouration. It typically occurs in the hands and feet but can also appear across the nose and ears. “This was a striking case of acrocyanosis in a patient who had not experienced it before his Covid-19 infection”, said co-author Dr Manoj Sivan, associate clinical professor and honorary consultant in rehabilitation medicine at the University of Leeds. “Patients experiencing this may not be aware that it can be a symptom of Long Covid and dysautonomia, and may feel concerned about what they are seeing. Similarly, clinicians may not be aware of the link between acrocyanosis and Long Covid. We need to ensure that there is more awareness of dysautonomia [malfunctioning of the nervous system] in Long Covid so that clinicians have the tools they need to manage patients appropriately.” Read full story Source: The Independent, 15 August 2023
  13. News Article
    The mother of a woman who took her own life weeks after being discharged from a mental health ward fears a "culture of cover up" within the NHS trust. Hannah Roberts, 22, died by suicide in 2018 and her mother Sally said there were "discrepancies" in the accounts of the talented musician's discharge. She feels an ongoing internal review into all Cambridgeshire & Peterborough NHS Foundation Trust (CPFT) suicides since 2017 should be independent. CPFT did not respond to her comments. The trust's chief executive Anna Hills previously said the internal review into 63 suicides would "be an important piece of work". Its announcement came after the trust was accused of adding to the records of Charles Ndhlovu, 33, the day after he took his own life to, in his mother's words, "correct their mistakes". Read full story Source: BBC News, 15 August 2023
  14. News Article
    The government has announced £250m in funding to provide an extra 5,000 NHS hospital beds in England this winter. Ministers say 900 new beds should be ready by January, with the remainder to follow soon after, boosting capacity and helping lower record waiting lists. The increase will mean nearly 100,000 permanent beds on wards and in A&E, available at the busiest time of the year - a 5% rise on current levels. NHS Providers said the extra capacity was needed "before winter begins". Miriam Deakin, director of policy and strategy at NHS Providers, said trusts would welcome the support but cautioned any new beds would need to be staffed. She added that, since winter is the busiest time of the year for urgent and emergency care, trust leaders would be concerned that the promised extra capacity is only expected to be in place by January. "For the best results, trusts would need these new beds before winter begins," she said. Pat Cullen, from the Royal College of Nursing, added: "The elephant in the room is who will staff these additional beds? Nursing staff are already spread too thinly over too many patients." Read full story Source: BBC News, 15 August 2023
  15. Event
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    Care experienced young people are much more likely to experience poorer health, wellbeing, social and educational outcomes compared with the general population. These inequalities are not new, but were exacerbated by Covid-19 as care leavers experienced disrupted relationships and reduced access to support services. Specific groups of care leavers are likely to face additional disadvantages, such as those from ethnic minority backgrounds, unaccompanied refugee and asylum seeking children and/or disabled young people. Yet the health and health inequalities of young care leavers have largely been ignored within policy and practice. As part of AYPH’s youth health inequalities programme we reviewed the available evidence and undertook a youth engagement project with young people to draw together what we know. In this webinar you will hear directly from young people who will share their experiences of the barriers they face in leading healthy lives and accessing healthcare services. We will also highlight the latest available data on care leavers and health outcomes, demonstrating where inequalities exist for young people aged 10-25. During the event we will be launching two major publications that explore in more detail the role of care experience in understanding young people’s health, this will be the first opportunity to hear the learnings and recommendations from this research. The webinar is hosted jointly by the Association for Young People's Health and Coram Voice and will be co-chaired by a young person with experience on this topic. We will be joined by a range of expert speakers – more information to follow soon. Register for the webinar
  16. Content Article
    Constipation can be a life–threatening issue for people with a learning disability who are at heightened risk from complications if it is left untreated. This campaign has been developed by NHS England to support people with a learning disability, their carers and people who work in primary care to recognise the signs of constipation. Resources have been co–created with input from the Down’s Syndrome Association, Mencap and Pathways Associates to ensure that they are fit for purpose. The resources aim to: Drive awareness of the seriousness of constipation Help people recognise the signs of constipation at an early stage Empower people to take action and ensure that people with a learning disability experiencing constipation get the right health support straight away Raise awareness of the steps which can be taken to prevent constipation.
  17. Content Article
    Patient Safety Learning invited David Osborn, a chartered safety and health practitioner and member of the Covid Airborne Transmission Alliance (CATA) to give a talk to the Safer Healthcare and Biosafety Network (SHBN) explaining what CATA is, its aims and objectives and its involvement with the UK Covid-19 Public Inquiry. Here is a recording of David's talk and the presentation he delivered.
  18. Event
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    Vaccine uptake in the UK is dropping, and we are failing to meet the WHO’s 95% coverage target. To help address this, we must understand people’s attitudes and experiences of vaccines, so we can grasp their concerns and better support them. Children’s attitudes are important too, because they must feel empowered to make health decisions. RSPH research with Children and Young People (CYP) shows that they trust vaccines and think they are important to their health. However, trust varies by ethnicity, with results showing that 85% of white CYP trust vaccines, in comparison to 71% of Asian and 74% of black CYP. Knowledge varies around which vaccines they think are available to them and they do not necessarily know which vaccines they can have. Whilst 61% of CYP understood how vaccines worked, they reported concerns about side effects (63%), safety (57%), whether they will hurt (55%) and the costs of accessing vaccines (16%). These findings have practical implications for practitioners working with CYP and delivering vaccines. In this webinar, we will explore: The impact of inequalities on access to vaccines and information about vaccinations. What challenges the public health workforce face in delivering vaccines. How the workforce – and others involved in vaccine delivery - can be supported to develop and deliver vaccines programmes Register for the webinar
  19. News Article
    Measures for avoiding medication errors with the injectable agents used routinely in anaesthesia care have been recommended in new guidelines from the Association of Anaesthetists. The guidelines, published in Anaesthesia, the journal of the Association of Anaesthetists, were drawn up "in response to requests for guidance from members in view of continuing incidents of medication errors and patient harm." The working party of UK anaesthesia experts that drew up the guidance emphasised the potential safety benefits of using prefilled and labelled syringes, as well as aids such as colour-coded medication trays. It highlighted that these were not yet in widespread use within the NHS. The group noted that unlike many healthcare workers, anaesthetists usually undertook medication preparation (transfer from labelled ampoules into unlabelled syringes) in a solo capacity, and that there could be an average of 10 medication administrations per anaesthetic procedure. Labelling errors have been reported in around 1–1.25% of peri-operative administrations, and medication substitutions in 0.2% of administrations during anaesthesia. The working party, chaired by Dr Mike Kinsella, honorary consultant in the Department of Anaesthesia at University Hospitals Bristol and Weston, said it aimed "to provide pragmatic safety steps" for use within operating theatres, as well as goals for the development of "a collaborative approach to reducing errors" as a basis for "instilling good practice." "It is important to acknowledge that every practitioner is open to error," the authors said, noting that the risk could increase over time during a case, especially if an anaesthetist's performance was diminished by fatigue. Read full story Source: Medscape, 10 August 2023
  20. News Article
    HSJ has published an interactive map of local NHS waits around England in June 2023, showing the pressures, with links to all the details by organisation and specialty. It shows the local picture on 18-week referral to treatment taken from the latest Referral to Treatment (RTT) waiting times data released by NHS England. View the map Read full story (paywalled) Source: HSJ, 14 August 2023
  21. News Article
    At-home smear tests should be introduced in Wales, campaigners say. Love Your Period campaigners said self-sampling at home would encourage more people to have the tests. For women aged 25 to 64 a smear test is an effective way of detecting human papillomavirus (HPV) and preventing cervical cancer. According to Public Health Wales data, cervical cancer is the most common cancer in women under the age of 35, with regular screening helping to reduce the risk of getting cervical cancer by 70%. The Welsh government said it followed advice from the UK National Screening Committee (UKNSC), which is yet to make a recommendation on self-sampling. However, it said Public Health Wales (PHW) was considering how the tests could be implemented in Wales. Currently, women in Wales are invited for a screening to check for the presence of high-risk HPV every five years. Campaigner Jess Moultrie said tests should be made available to those who have experienced trauma and find the process of in-hospital smears triggering. "Being able to do it at home gives you that power, you can be a little bit more relaxed, it's not as intimidating." Read full story Source: BBC News, 14 August 2023
  22. News Article
    A Scottish research firm set up by a dementia expert who quit the NHS because of insufficient “infrastructure” has developed a blood test to allow doctors to identify Alzheimer’s disease earlier. Scottish Brain Sciences, based in Edinburgh, announced it will collaborate with Roche Diagnostics on a series of projects, which the former’s founder, Craig Ritchie, said could have “big impacts”. Ritchie, who has led dozens of drug trials and pilots a European network on preventing Alzheimer’s, had been advocating the need to create new brain health centres across Scotland. Read full story (paywalled) Source: The Times, 14 August 2023
  23. News Article
    Medics have welcomed clarification from health officials over when the upcoming flu and Covid-19 vaccination programme will begin. NHS England had been criticised for pushing back the start date a month with pharmacists saying the change of plan would likely “catch patients off guard”. While school-aged children will be able to receive the flu shot from 1 September, adults were not expected to start getting flu and Covid jabs until October, a month later than recent years. Officials briefed that the later start time was so sites can co-administer both vaccines wherever possible, to make it more convenient, and to ensure protection in later winter months – typically when viruses are more likely to spread. But NHS England was criticised for a lack of transparency and communication, as healthcare teams had been preparing to provide the service as usual from September. NHS England said to maximise and extend protection during the winter and through the period of greatest risk in December and early January 2024, care home residents and care home staff must start receiving their jabs from 2 October, and other eligible flu and Covid cohorts from 7 October. However, in updated guidance officials said that as some firm commitments and appointments have already been made, any patient wishing to receive their vaccination in September will be allowed to do so. Most people are still likely to have their vaccines in October, officials believe. Responding to news that NHS England will, if needed, now allow practices to deliver both vaccination programmes from September rather than October, Dr Katie Bramall-Stainer, chair of GPC England at the British Medical Association (BMA), said: “This news is very welcome, coming after the BMA made clear yesterday to NHS England that shifting the entire programme at the last minute to October would not only cause widespread confusion, but also serious disruption as flu clinics would have to be rearranged to fit the new timetable." Read full story Source: inews, 11 August 2023
  24. News Article
    Two-thirds of NHS cancer waiting time targets are expected to be scrapped in England, in a move the health service says aims to catch cancers earlier. NHS bosses want to reduce the number of targets, most of which have been routinely missed in recent years, from nine to three. They say the plan is backed by leading cancer experts and will simplify the "outdated" standards. But some are concerned about the move. Pat Price, oncologist, visiting professor at Imperial College London and Head of the charity Radiology UK, said current performance was "shockingly bad", and while too many targets could be disruptive, "the clear and simple truth is that we are not investing enough in cancer treatment capacity". Read full story Source: BBC News, 14 August 2023
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    As we grapple with the rising burden of chronic wounds in the UK, Public Policy Projects is excited to bring together key stakeholders from across the UK at a half-day conference that aims to examine how we can improve woundcare by breaking silos, delivering on joint-up care and raising the salience of the challenges. Following on from this year’s series of four roundtables focusing on challenges and opportunities within woundcare, PPP’s Woundcare Conference will serve as the launch of our flagship woundcare report. Our work will identify opportunities for efficiency gains and produce recommendations for reducing inequalities of access and outcomes for chronic wounds. It will provide an invaluable opportunity for our delegates and speakers to engage in a dynamic dialogue on how we can go further for wound healing, and improve outcomes, costs and population health through delivering better wound care. Register for the conference
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