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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This toolkit provides information about how the US Department of Health and Human Services Office of the Director General conducted recent medical record reviews to identify patient harm. It outlines the decision criteria for adverse events and describes the methods used in the report, 'Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm' in October 2018, building upon a broader series of reports about adverse events in hospitals and other health care settings.
  2. News Article
    In the most deprived areas of England and Scotland, the nearest 24/7 accessible defibrillator is on average a round trip of 1.8 km away—over a mile—according to a pioneering study supported by the British Heart Foundation (BHF). The researchers, led by Dr Chris Wilkinson, senior lecturer in cardiology at Hull York Medical School, used data from national defibrillator network The Circuit to calculate the median road distance to a defibrillator with unrestricted public access across Great Britain's 1.7 million postcodes. Among the 78,425 defibrillator locations included, the median distance from the centre of a postcode to a 24/7 public access defibrillator was 726.1 metres – 0.45 miles. In England and Scotland, the more deprived an area was, the farther its average distance from a 24/7-accessible defibrillator – on average 99 metres more in England, and 317 metres farther in Scotland for people living in the most compared with the least deprived areas. There was no link between defibrillator location and deprivation in Wales. The researchers said they hoped the findings, presented at the European Society of Cardiology (ESC) Congress in Amsterdam and published in the journal Heart, would lead to more equal access to defibrillators. They noted that there were over 30,000 out-of-hospital cardiac arrests (OHCA) annually in the UK; in England nearly 30% happened at weekends, and 40% between 6pm and 6am. Read full story Read research study: Automated external defibrillator location and socioeconomic deprivation in Great Britain (28 August 2023) Source: Medscape, 29 August 2023
  3. Content Article
    The early use of automated external defibrillators (AEDs) improves outcomes in out-of-hospital cardiac arrest (OHCA). This study in the journal Heart investigated AED access across Great Britain according to socioeconomic deprivation. The authors found that in England and Scotland, there are differences in distances to the nearest 24/7 accessible AED between the most and least deprived communities. They concluded that equitable access to ‘out-of-hours’ accessible AEDs may improve outcomes for people with OHCA.
  4. Event
    until
    This year's World Patient Safety Day on 17 September will focus on engaging patients for patient safety, in recognition of the crucial role patients, families and caregivers play in the safety of healthcare. Ahead of World Patient Safety Day this webinar will provide an opportunity for those involved in patient safety to hear from patient safety leaders and discuss the opportunities and barriers to increasing patient engagement. It is co-hosted by the Patient Safety Commissioner for England and the charity Patient Safety Learning. The webinar will consist of a panel discussion and question and answer session with the following speakers: Dr Henrietta Hughes, Patient Safety Commissioner for England Jono Broad, Patient leader and a member of the South West Personalised Care Team Helen Hughes, Chief Executive of Patient Safety Learning Tracey Hanson, Patient Safety Partner at Central and North West London NHS Foundation Trust Sign up for the webinar
  5. News Article
    The NHS workforce plan will cost £50 billion and result in the health service employing half the public sector by the 2030s, analysis concludes today. Jeremy Hunt, the chancellor, has in effect “stolen more than a decade’s worth of budgets” from his successors by setting out plans to hire almost a million extra NHS staff without a clear way to pay for them, the Institute for Fiscal Studies (IFS) says. Hunt has been urged to use his autumn statement to start setting out whether tax rises, borrowing or cuts elsewhere will be used to fund the “massive spending commitment”. Read full story (paywalled) Source: The Times, 30 August 2023
  6. News Article
    Targeted screening of patients with type 2 diabetes could more than double new diagnoses of heart conditions, a study suggests. When applied at a larger scale, such an approach could translate into tens of thousands of new diagnoses, researchers believe. Conditions such as coronary artery disease, atrial fibrillation and heart failure affect millions of people worldwide, causing a large number of deaths and increasing healthcare costs. Treatments are available that can prevent stroke or acute heart failure, but systematic screening is not currently common practice. Those living with conditions such as type 2 diabetes or chronic obstructive pulmonary disease (COPD) – a group of lung conditions that cause breathing difficulties – are at high risk of such conditions. A team of researchers led by Dr Amy Groenewegen, from the University Medical Centre Utrecht in the Netherlands, has developed a three-step screening process to detect conditions in high-risk people at an early stage. Study author Dr Groenewegen said: “An easy-to-implement strategy more than doubled the number of new diagnoses of heart failure, atrial fibrillation and coronary artery disease in high-risk patients.” Read full story Source: Independent, 29 August 2023
  7. News Article
    All tech support for flu and covid vaccinations will be switched off on Thursday after NHS England decided against extending its contract with its supplier in favour of developing an in-house system, according to HSJ. NHSE last week told suppliers System C and Graphnet it would not extend the contract for the National Immunisation Management Service – just one week before the contract ends. NIMS, provided by the two British firms in partnership with NHS South Central and West Commissioning Support Unit, has been used for the last three years to manage the vaccination programme. Its functionalities include a single data store holding vaccination records for more than 60 million people, a call and recall service that can identify and contact groups of eligible individuals according to age and clinical priority, and reporting and analysing of vaccination activity in “near real time”. NHSE informed System C it would not extend the contract last Thursday – five working days before it was due to expire, according to a message from System C to customers, seen by HSJ. In its message, System C said: “This means that all functionality, including the NIMS application programming interface links to third party booking systems, all outgoing feeds and extracts, NIMS dashboards and the point of vaccination data capture application will stop working after 31 August.” There is currently “significant usage” of the system by GPs and trusts, which means NIMS users “may need to take action to deal with the retirement of the system” – the message stated. Read full story (paywalled) Source: HSJ, 30 August 2023
  8. News Article
    The number of appointments and treatments postponed by strike action in the NHS in England is nearing one million. The 48-hour walkout by consultants in England last week saw more than 45,000 appointments being cancelled. It brings the total number of postponed hospital appointments since industrial action began in the NHS in December to 885,000. Once mental health and community bookings are included, it tops 944,000. The true total is likely to be even higher, as services have stopped scheduling appointments on strike days and these will not be included in the figures released by NHS England. Alongside consultants, junior doctors, nurses, physios, ambulance workers and radiographers have also walked out at various stages. NHS national medical director Professor Sir Stephen Powis said: "Industrial action continues to have a huge impact on the NHS, and on the lives of patients and their families. This strike took place into a bank holiday weekend, when NHS activity is generally lighter, but many services have for some time avoided scheduling any planned appointments for strike days in order to prioritise emergencies. This means the true impact of this action will be even higher, and as we move into September, the extraordinary cumulative effect of more than nine months of disruption poses a huge challenge for the health service, as staff work tirelessly to tackle the backlog." Read full story Source: BBC News, 29 August 2023
  9. Content Article
    In this blog, Sling the Mesh founder Kath Sansom highlights the variation in medical treatment depending on where you live in the world. Describing patient safety advocacy as "like a giant game of chess—but a hideous version where innocent people get hurt," she describes recent developments in the use of pelvic mesh globally. New Zealand recently suspended the use of a particular type of pelvic mesh at the same time as a Canadian study recommended its use for stress urinary incontinence (SUI). Kath gives a brief history of mesh sling suspension and argues that patient safety needs joined up thinking to protect women around the world.
  10. Content Article Comment
    If you have experience of NHS and/or private orthodontic or dental treatment and want to share your story, you can do so in our community conversation:
  11. Content Article
    Two years after his 13-year-old child died needlessly in hospital, Paul Laity reflects on life without her. Martha Mills died of septic shock due to a series of serious failures in her care after she injured her pancreas in a cycling accident. Her father Paul talks about the ongoing pain of grief, and the additional burden of knowing that Martha's death was preventable, caused by the complacency of her doctors and a culture in the hospital that meant consultants were reluctant to ask expert advice from paediatric ICU. "Martha’s avoidable death was unusual in that the prime causes weren’t overwork or a lack of resources, but complacency, overconfidence and the culture on the ward. What upsets me most was that the consultants – a different one most days – took a punt that she was going to be OK over the weekend. No one assumed responsibility; they hoped for the best rather than playing safe. Was everything done for Martha that could have been done? Emphatically not. It’s very hard to live with this knowledge. But just as hard is the recognition that I, too, didn’t do enough." Further reading ‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (The Guardian, 3 September 2022) Prevention of Future Deaths Report: Martha Mills (28 February 2022)
  12. 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.  Kath talks to us about why she set up Sling the Mesh and the significant impact that campaigning has on her life. She also highlights the need to establish systems that will identify and prevent avoidable harm, including long term tracking to investigate trends of harm, reporting of industry payments to clinicians and making logging side effects mandatory for healthcare professionals.
  13. Content Article
    Patients are increasingly describing their healthcare experiences publicly online. This has been facilitated by digital technology, a growing focus on transparency in healthcare and the emergence of a feedback culture in many sectors. The aim of this study was to identify a typology of responses that healthcare staff provide on Care Opinion, a not-for-profit online platform on which patients are able to provide narrative feedback about health and social care in the UK. The authors used framework analysis to qualitatively analyse a sample of 486 stories regarding hospital care and their 475 responses. Five response types were identified: non-responses, generic responses, appreciative responses, offline responses and transparent, conversational responses. The key factors that varied between these response types included the extent to which responses were specific and personal to the patient story, how much responders' embraced the transparent nature of public online discussion and whether or not responders suggested that the feedback had led to learning or impacted subsequent care delivery. Staff provide varying responses to feedback from patients online, with the response types provided being likely to have strong organisational influences. The findings offer valuable insight and have both practical and theoretical implications for those looking to enable meaningful conversations between patients and staff to help inform improvement. The authors suggest that future research should focus on the relationship between response type, organisational culture and the ways in which feedback is used in practice.
  14. News Article
    Delays in patient care and a lack of consultant support have left junior medics fearing for their mental health, an NHS England investigation has discovered. Junior doctors described haematology services delivered from University Hospitals Birmingham’s Heartlands Hospital as “chaotic”. Their concerns are raised in a report by NHS England Workforce, Training and Education (formerly Health Education England). UHB’s haematology service has been under scrutiny since 2021, when HSJ revealed whistleblower concerns over patient safety, including a series of blood transfusion’ never’ events. The WTE team visited UHB in April. As a result, the haematology service is now subject to the General Medical Council’s enhanced monitoring regime. This means intensive support is given to trainees and the trust to improve medical training. UHB’s obstetrics and gynaecology department is also under enhanced monitoring. The WTE report warns that consultants working across multiple sites left trainee medics at Heartlands without sufficient support and supervision. Most conversations with consultants were via telephone, leaving juniors feeling “unsupported and insecure”. The report stated: “Trainees described the workload … as chaotic and some reported the stress … was affecting their mental health… Some reported they do not feel valued, and the panel heard examples of people crying every day. Most described their roles as 100 per cent service provision… [they] reported very limited learning opportunities overall.” Read full story (paywalled) Source: HSJ, 24 August 2023
  15. News Article
    Just three “slightly unhealthy traits” in mid-life increase the risk of early death by a third, research suggests. The study found people carrying extra weight in their 40s and 50s who also had slightly raised blood pressure, cholesterol or blood sugar levels were also 35 per cent more likely to have a heart attack or stroke over the next three decades. Researchers warned that middle-aged people with this “cluster of slightly unhealthy traits” – known as metabolic syndrome – typically had a heart attack or stroke two years earlier on average than healthier people the same age. Dr Lena Lönnberg, of Västmanland County Hospital, Sweden, who was lead researcher for the study, said: “Many people in their 40s and 50s have a bit of fat around the middle and marginally elevated blood pressure, cholesterol or glucose but feel generally well, are unaware of the risks and do not seek medical advice. “In fact, most people live with slightly raised levels for many years before having symptoms that lead them to seek healthcare.” She warned that because the individual “unhealthy traits” did not usually make people feel unwell, most people were unaware of the risks combined with excess weight. An estimated one in four UK adults has metabolic syndrome, with rising obesity levels one of the main drivers. On their own, diabetes, high blood pressure, and obesity can damage the blood vessels. But even if patients only have mild versions of each condition, experts warn having the three together can be particularly dangerous. Read full story (paywalled) Source: The Telegraph, 25 August 2023
  16. News Article
    A mum suffered a perforated bowel and sepsis after being told she was anxious and should take constipation medication and drink peppermint tea. Farrah Moseley-Brown was in "agonising pain" after having her second son, Clay, but the hospital sent her home. Because of the delay in treating her, Ms Moseley-Brown, 28, of Barry, Vale of Glamorgan, now has a stoma. Cardiff and Vale health board admitted failures in her care and gave its "sincere apologies". Since the error, Ms Moseley-Brown has turned to TikTok to inform people about the dangers of sepsis and has had 15 million views one one video alone. She was booked into University Hospital Wales, Cardiff, for a Caesarean on 7 May 2020. After Clay was born, Ms Moseley-Brown lost about two-and-a-half pints of blood and needed further surgery to stem the bleeding. "I felt really unwell and I said this to the nurses and the staff at the hospital which they didn't listen to. They kept saying it was after-pain but it was just agonising," Ms Moseley-Brown said. Read full story Source: BBC News, 25 August 2023
  17. 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
  18. 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
  19. 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
  20. 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.
  21. 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.
  22. 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.
  23. 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.
  24. 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.
  25. 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.
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