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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. News Article
    Covid cases in England have almost doubled in a month after the rise of two new variants. According to the most recent government statistics available, 875 cases were logged in England on August 11, compared to just 449 a month earlier. Hospital admissions have also risen by a fifth in a week. UKHSA statistics show Covid cases in England rose from a seven-day rolling average of 373 on July 8 to 879 as of August 8. Also, 589 out of 6,500 neighbourhoods in England had detected at least three Covid cases in the week to August 12. The uptick comes after reports of a new variant called Eris which makes up one in four new cases. Also, another strain nicknamed Pirola is quickly spreading globally. The US is also seeing an increase in hospital admissions with coronavirus, its first significant uptick since December 2022. The UK Health Security Agency (UKHSA) said they are unsettled by the variant and suggested the rapid spread could suggest an international transmission. Christina Pagel, a member of the Independent Scientific Advisory Group for Emergencies that advises on the virus, said: "Without ramping up surveillance, and in the face of waning immunity, we are travelling into winter more vulnerable and with blinkers on." Prof Pagel predicted the new wave could cause extreme pressure on the health service, with a repeat of last winter’s “unprecedented” NHS crisis of Covid, flu and respiratory virus that came all around the same time. Read full story Source: Independent, 24 August 2023
  2. News Article
    Top young cancer researchers are leaving the UK in a “brain drain” fuelled by the continuing failure to reach an agreement over the EU’s study programme, scientists warn. The two-and-a-half-year delay in joining the £85bn Horizon Europe scheme, the largest collaborative research programme in the world, has “damaged the UK’s reputation” and made it more difficult to attract and retain the brightest researchers into the nation’s labs. Cancer Research UK (CRUK) surveyed 84 cancer specialists about Horizon Europe and found that three-quarters of respondents favoured association with the programme compared with only 11% who wanted the UK to go it alone with the government’s plan B, known as Pioneer. Prof Julian Downward, head of the Oncogene Biology Lab at the Francis Crick Institute in London, said: “We need Horizon Europe very badly. The current situation is damaging UK science every day. We are losing top junior faculty regularly who decide to move to EU countries so they can take up European Research Council grants.” Read full story Source: Guardian, 25 August 2023
  3. News Article
    Thirty families are starting legal action against the government, care homes and several hospitals in England over the deaths of their relatives in the early days of the Covid pandemic. The families argue not enough was done to protect their loved ones from the virus. They are claiming damages for loss of life and the distress caused. The government says it specifically sought to safeguard care home residents using the best evidence available. The legal claims focus on the decision in March 2020 to rapidly discharge hospital patients into care homes without testing or a requirement for them to isolate. The cases follow a 2022 High Court judgement that ruled the policy was unlawful - as it failed to take into account the risk to elderly and vulnerable care home residents of asymptomatic transmission of the virus. One of the cases is being brought by Liz Weager, whose 95-year-old mother Margaret tested positive for the virus in her care home in May 2020 and died later in hospital. "What was happening in the management of those care homes? What advice were they having?" Liz asks. "It goes back to the government. There was a lack of preparedness, which then translated down to the care home." Read full story Source: BBC News, 25 August 2023
  4. Content Article
    In this blog post, Charlotte Augst looks at the impact of the Lucy Letby conviction on views of patient safety and accountability. The case has brought debates about patient safety into the mainstream media and public consciousness, and rather than focus simply on one extreme case, she believes it is important to look into common patterns in the NHS that lead to harm. She highlights that while such an awful case—where a healthcare professional caused deliberate harm to the most vulnerable patients—is shocking, it is also rare. She outlines a need to focus on the systemic issues that are resulting in repeated harm to patients, particularly in maternity services. Patients continue to be harmed because of rifts between management and clinical staff, the inability of the healthcare and regulatory system to really listen to patients, systemic discrimination and cognitive bias. Charlotte argues that while we may find ourselves focusing on the character of a nurse who committed such heinous crimes, we need to pay equal attention to the normalised behaviours and attitudes that harm patients and take place every day throughout the NHS.
  5. Content Article
    This study in Intensive and Critical Care Nursing examined the association between safety attitudes, quality of care, missed care, nurse staffing levels and the rate of healthcare-associated infection (HAI) in adult intensive care units (ICUs). The authors concluded that positive safety culture and better nurse staffing levels can lower the rates of HAIs in ICUs. Improvements to nurse staffing will reduce nursing workloads, which may reduce missed care, increase job satisfaction, and, ultimately, reduce HAIs.
  6. Content Article
    During pregnancy, and up to one year after birth, one in five women will experience mental health issues, ranging from anxiety and depression to more severe illness. For those women experiencing mental ill-health, barriers often exist preventing them from accessing care, including variation in availability of service, care, and treatment. These are often worsened by cultural stigma, previous trauma, deprivation, and discrimination. This document by the Royal College of Midwives outlines recommendations to ensure that women are offered, and can access, the right support at the right time during their perinatal journey.
  7. Content Article
    When the Covid-19 pandemic started, video consulting became standard practice for many GPs, who became rapidly acquainted with the technology for video calls. Doctors worked on improving their video consulting technique, not knowing for how long they might have to limit in-person consultations. Now that vaccination has reduced the risks of face-to-face appointments, the vast majority of GP practices rarely use video consultation, and fewer than 1% of consultations were conducted this way in England in May 2023. In this BMJ article, GP Helen Salisbury looks at the reasons for this decline in the use of video calls, arguing that face-to-face consults allow for a more accurate and safe diagnostic process and facilitate building rapport between healthcare professionals and patients.
  8. Content Article
    The National Health Executive Podcast brings you closer to the leaders, influencers and decision makers responsible for building, shaping and delivering transformational health and social care services across the UK. Covering everything from the net-zero, digital transformation, mental health, pharma, estates, workforce and training, our hosts brings you unique and exclusive podcast episodes packed full of news, views and insight from healthcare professionals and experts responsible for shaping the future of the UK health sector.
  9. Content Article
    This infographic on Good Work Design by the Chartered Institute for Ergonomics & Human Factors (CIEHF) outlines how a three-phase, human-centric approach to designing work can result in work that people enjoy and can excel at. It lists the elements of what good work looks like to ensure both the organisation and its workers can improve performance. To go alongside the infographic, the authors presented a webinar examining how to design good work and looking at the some of the strategies involved.
  10. Content Article
    Delays in the handover of patient care from ambulance crews to emergency departments (EDs) are causing harm to patients. A patient’s health may deteriorate while they are waiting to be seen by ED staff, or they may be harmed because they are not able to access timely and appropriate treatment. This national investigation sought to examine the systems that are in place to manage the flow of patients through and out of hospitals and consider the interactions between the health and social care systems (the ‘whole system’). This report brings together the findings from the investigation’s three interim reports and provides an update since they were published. You can view the interim reports on the hub: Interim report 1 (16 June 2022) Interim report 2 (3 November 2022) Interim report 3 (27 February 2023)
  11. Content Article Comment
    @Cath Marsland Are you able to access it now?
  12. Community Post
    Hi Fiona, As you are already a member of the hub, please email support@PSLhub.org with a request to be added to the group.
  13. Content Article
    In June 2022, General Sir Gordon Messenger and Dame Linda Pollard published their final report on the review of leadership and management in the health and social care sector, as commissioned by the Secretary of State for Health and Social Care in October 2021. This briefing by NHS Providers summarises the key areas covered by the report, grouping recommendations under the following headings: Training  Development Equality, diversity and inclusion  Challenged trusts, regulation and oversight
  14. Content Article
    Diagnostic error research has largely focused on individual clinicians’ decision making and system design, largely overlooking information from patients. This article in the journal Health Affairs analysed a unique data source of patient- and family-reported error narratives to explore factors that contribute to diagnostic errors. The analysis identified 224 instances of behavioural and interpersonal factors that reflected unprofessional clinician behaviour, including ignoring patients’ knowledge, disrespecting patients, failing to communicate and manipulation or deception. The authors concluded that patients’ perspectives can lead to a more comprehensive understanding of why diagnostic errors occur and help develop strategies for mitigation. They argue that health systems should develop and implement formal programs to collect patients’ experiences with the diagnostic process and use these data to promote an organisational culture that strives to reduce harm from diagnostic error.
  15. Content Article
    A Kind Life works with NHS organisations to help them shape a culture that cultivates kindness and nurtures high performance. The company offers a range of training courses and programmes focused on areas such as recruitment, leadership, feedback and conflict resolution.
  16. News Article
    The use of surgical mesh to treat a common childbirth injury is now suspended in New Zealand because of safety concerns. The extraordinary step, which follows a similar move in the United Kingdom, was announced today by Te Whatu Ora. It is being celebrated by a woman who spearheaded a campaign to highlight the harrowing mesh injuries suffered by her and many other Kiwi women. “It is an acknowledgement that their concerns were not just in their heads,” Sally Walker told the Herald. “It will give us some hope.” About 100 women around the country who are on waiting lists for urogynaecological surgeries involving mesh are being contacted by doctors to tell them their operations for stress urinary incontinence are on hold. The Director-General of Health Dr Diana Sarfati said the Surgical Mesh Roundtable (MRT), an oversight and monitoring group chaired by the Ministry of Health, had been investigating a “pause” since earlier this year. The group’s assessment was that the balance of benefit and harm from the procedure would be improved by the series of additional measures already planned, and it recommended a pause until those measures were substantively in place. “After considering the MRT’s assessment, I have decided to support a pause to allow the following steps to be put in place to reduce the harms linked to the procedure as much as possible,” said Sarfati. Read full story Source: NZ Herald, 22 August 2023
  17. Content Article
    Publicly available data from the Office for Health Improvement and Disparities (OHID) shows a persistently high number of excess deaths involving cardiovascular disease (CVD) in England since the beginning of the pandemic. This analysis of by the British Heart Foundation looks at this situation in more detail.
  18. Content Article
    This is the report of a review into how the executive leadership of the NHS could be better supported and empowered to ensure the best possible service is delivered for patients. Sir Ron Kerr was commissioned by the Department of Health and Social Care (DHSC) to conduct the review, which focused on three issues in particular: The expectations and support available for leaders - particularly those in challenging organisations and systems The scope for further alignment of performance management expectations at the organisational and system level The options for reducing the administrative burden placed on executive leaders The report describes the methodology of the review, outlines its findings and makes a number of recommendations around these issues.
  19. Content Article
    The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 aimed to: minimise burdens on public, independent and third sector employers and ensure businesses in UK are not placed at competitive disadvantage relative to EU counterparts offer good standards of protection to healthcare workers from risk of sharps injury at work see a fall in sharps injury numbers. This post implementation review (PIR) aimed to assess the success of these objectives. It found that: stakeholder consultation provided evidence of the increasing use of safer sharps across all healthcare sectors. evidence from RCN research and HSE inspections indicates that risks to healthcare workers from sharps injuries remains high. The policy conclusion from this evidence is that the Regulations are still required, and that the Regulations’ objectives cannot be met with a system that imposes less burden to business.
  20. Content Article
    The Prescribing Safety Assessment (PSA) is a 60-question exam required as part of UK medical training to progress from FY1 to FY2. This independent review into the PSA was commissioned by the Medical Schools Council (MSC) together with the British Pharmacological Society (BPS) in the summer of 2022. It suggests a strategic future direction for the PSA and addresses how the PSA has impacted prescribing assessment and practice for medical students and Foundation Year 1 (FY1) doctors. It is intended to support national decision making about the future of UK prescribing assessment in the context of the imminent introduction of the Medical Licensing Assessment (MLA).
  21. Content Article
    Calibration, defined as alignment between a person’s diagnostic accuracy and their confidence in that accuracy, is an essential component of diagnostic excellence. Miscalibration—the misalignment between a person’s diagnostic accuracy and their confidence in that accuracy—can manifest as either overconfidence or underconfidence and can have serious consequences for patient diagnosis. This resource about calibration from the US Agency for Healthcare Research and Quality (AHRQ) is primarily aimed at individual clinicians whose scope of practice includes diagnosis. It focuses on processes involved in making a diagnosis and the outcome of giving an explanatory label to patients after these processes unfold.
  22. Content Article
    This study in the Journal of Medical Virology aimed to assess the extent and the disparity in excess acute myocardial infarction (AMI)-associated mortality during the pandemic, focusing on the outbreak of the Omicron strain. Using data from the US Centers for Disease Control and Prevention's (CDC's) National Vital Statistics System, the authors found that excess death, defined as the difference between the observed and the predicted mortality rates, was most pronounced for the 25–44 years age group. Excess deaths ranged from 23%–34% for the youngest compared to 13%–18% for the oldest age groups. The trend of mortality suggests that age and sex disparities have persisted even through the Omicron surge, with excess AMI-associated mortality being most pronounced in younger-aged adults.
  23. Content Article
    The UK spends significantly less on capital, such as buildings and equipment, than most other Organisation for Economic Co-operation and Development (OECD) countries. This may contribute to its poor performance on outcomes compared with similar countries.  This Health Foundation report analyses trends in the capital budget, comparing the UK with international averages. Using annual data from all NHS trusts in England. It then focuses on trends in the capital spending of NHS trusts to analyse where money has been spent and where there are areas of need. It then analyses the implications of recent capital spending, with a specific focus on NHS trusts’ maintenance backlog. The report concludes with a discussion of the trends in capital spending and capital levels, and implications and recommendations for future health care funding.
  24. Content Article
    .As healthcare organisations continually strive to improve, there is a growing recognition of the importance of establishing a culture of safety. This handbook was published by Healthcare Improvement Scotland to support NHS board maternity services to: understand the importance of safety culture. undertake a patient safety climate survey. understand what the survey results are telling them. develop an improvement plan to address areas that have been highlighted. It includes: the Maternity Services Patient Safety Survey. template letters for NHS boards to adapt for local use. an example improvement plan template.
  25. Content Article
    Despite the prevalence of diabetes amongst individuals with Serious Mental Illness (SMI), diabetes care is not currently audited within mental health inpatient settings as it audited in physical health settings. This project piloted an audit to assess the diabetes care within London NHS Mental Health Trusts. The Health Innovation Network in partnership with South London and Maudsley NHS Foundation Trust (SLaM) developed and piloted a diabetes audit. Following the SLaM pilot, the audit was completed by all nine London Mental Health Trusts. A diverse approach was taken to spread and adoption. This included piloting the audit within one MH Trust, refining, and then rolling out the audit to eight London Mental Health Trusts.
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