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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Event
    This webinar organised by WHO Europe will explore the access gaps in rural areas and the role that PHC plays in tackling this issue. Panellists from diverse backgrounds will delve into the multifaceted factors influencing access in rural, isolated and dispersed population areas. Register for the webinar
  2. Content Article
    In this article for the Lancet, Richard Horton reflects on the failure of medical education systems around to look after their students. He highlights reports of large proportions of medical students reporting burnout and feeling unappreciated and calls for an overhaul of the medical education system.
  3. Content Article
    Integrated Care Boards (ICBs) are responsible for commissioning and funding care provided by the various healthcare providers in its area, such as hospital trusts and community trusts. This blog offers patients practical advice on how to hold their ICB to account, for example, by raising questions at their ICB's monthly or bimonthly meeting.
  4. Content Article
    The UK is suffering from a chronic shortage of midwives, a shortage that has had an inevitable impact on maternity safety. While services in Scotland, Wales and Northern Ireland certainly have their challenges, it is England where the problems have been most severe, with a current estimated shortage of 2,500 midwives. The result is that midwives and working an estimated 100,000 hours’ unpaid overtime every week— burnout is widespread and the NHS is struggling to retain staff. This report by the Royal College of Midwives makes several suggestions to recruit and retain midwives in our maternity services. These include improving the quality of midwifery education. paying student tuition fees and employers developing more flexible working practices.
  5. News Article
    Rishi Sunak has failed to deliver on his key promise to cut NHS waits, the health secretary has admitted, as new figures show that the overall waiting list now stands at 7.5 million. An extra 300,000 patients are waiting for hospital care compared with January last year, when the prime minister pledged that, under his government, “NHS waiting lists will fall and people will get the care they need more quickly” . Victoria Atkins, the health secretary, admitted that Sunak had failed to deliver on his promise but argued: “I don’t think anyone could have thought that it was an easy promise to make and it was going to be easy to achieve.” Read full story (paywalled) Source: The Times, 11 April 2024
  6. News Article
    The headline A&E target was missed in March despite NHS England’s controversial last-ditch attempts to deliver it. Four hours A&E performance was 74.2 per cent in March—1.8 percentage points lower than NHSE’s 76 per cent threshold—but up from 71.5 per cent in the same month last year. NHSE’s attempts to improve four hours performance ahead of a year-end deadline—which included new cash incentives, asking directors to sign personal commitments, and encouraging trusts to focus on less sick patients—saw March performance 3.3 percentage points higher than 70.9 per cent in February. Around a third of acute trusts (38 of 119) met the 76 per cent target in March–more than double the number of trusts above the threshold in February (15). An interim ambulance response time for category 2 incidents, set at 30 minutes, was also missed in 2023-14—despite some improvement, and despite the government providing significant extra funding. The average response time across the year was 36m 23s—better than 2022-23 when it was 50m—but much worse than the pre-covid average of 21m 47s in 2018-19 and 23m 50s in 2019-20. Many ambulance trusts have continued to struggle with delays in handovers to A&E departments and South Western Ambulance Service Foundation Trust – which has seen some of the worst delays over the winter—averaged 45m 54s for category 2 incidents in March. Read full story (paywalled) Source: HSJ, 11 April 2024
  7. News Article
    A woman who feared she was having a heart attack said she spent nine days in a hospital staff room because of a shortage of beds. Zoe Carlin, 23, was admitted to Altnagelvin Hospital in Londonderry in March after experiencing severe chest pain. She said she spent more than a week in a “locker room” where she had to use a hand bell to call staff during what she described as a “dehumanising” ordeal. The Western Health and Social Care Trust (WHSCT) said it faced "extreme pressures" in its hospital emergency departments but could not comment on individual cases due to confidentiality. “For the full nine days I was in this alcove,” she told BBC Radio Foyle’s North West Today programme. “It’s basically the nurses' locker room. You can see the nurses’ lockers with their names on them. They [staff] just said there’s not enough beds,” she added. A privacy screen did not fully cover the room’s doorway and she had no access to a private bathroom. She said she was forgotten about at meal times on three occasions. A spokesperson for WHSCT said, "We are acutely aware of the continuing challenges and extreme pressures not just in our emergency departments but across both of our acute hospital sites with full escalation of beds on all wards and departments. In the Western Trust, when we learn of examples where care falls below the standard we expect, we review the circumstances and explore ways to improve care in the future." Read full story Source: BBC News, 11 April 2024
  8. News Article
    Adult transgender clinics in England are facing a Cass-style inquiry into how they treat patients after whistleblowers raised concerns about the care they provide. NHS England has announced that it is setting up a review of how the seven specialist services operate and deliver care after past and present staff shared misgivings privately during a previous investigation. As a first step, NHS England will send “external quality improvement experts” into each of the clinics to gather evidence about how they care for patients, to help guide the inquiry’s direction. The move follows the publication on Wednesday of a landmark review by Dr Hilary Cass, a former president of the Royal College of Paediatrics and Child Health, which recommended sweeping changes in the way that the health service treats under-18s who are unsure about their gender identity. In a letter responding to Cass’s report, which NHS England sent on Tuesday to the seven trusts that host adult gender dysphoria clinics (GDCs), it told them: “We will be launching a review into the operation and delivery of the adult GDCs, alongside the planned review of the adult gender dysphoria service specification.” Robbie de Santos, director of campaigns and human rights at Stonewall, an LGBT rights charity, said: “Gender healthcare for adults in the UK is, simply put, not fit for purpose. Many trans adults are being forced to go private at great personal expense to avoid waiting lists in excess of half a decade. We would welcome a review aimed at tackling this unacceptable state of affairs and building capacity into the system.” Read full story Source: Guardian, 10 April 2024
  9. News Article
    A statutory inquiry into deaths of mental health patients will now cover fatalities that took place as late as December 2023. The inquiry’s investigations are focused “on the trusts which provide NHS mental health inpatient care in Essex”. This includes: “Essex Partnership University Foundation Trust, and the North East London Foundation Trust and their predecessor organisations, where relevant.” NELFT was not specifically mentioned in the original terms of reference although the inquiry told HSJ it had been within the original scope. The inquiry will also now cover deaths of NHS patients from Essex who died when under the care of private sector providers. The inquiry’s previous terms of reference covered a period ending in 2020. However, the inquiry’s chair, Baroness Kate Lampard, proposed extending the inquiry’s scope last year due to “ongoing concerns” over services at EPUFT. Read full story (paywalled) Lampard Inquiry: Terms of reference Source: HSJ, 11 April 2024
  10. Event
    until
    The federal Patient Safety and Quality Improvement Act was created in 2005 and established a national patient safety database and a system of Patient Safety Organizations (PSOs) in the US. Although PSOs have existed for more than 15 years, healthcare organisations still struggle to identify the best reporting structure and how to most effectively utilise protections in relation to patient safety work. In this ECRI webinar, Partner and Owner of Bolin Law Group, Andrew Bolin, will discuss: The establishment of a Patient Safety Evaluation System and how it relates to PSOs The differences between state protections and federal protections How to work with surveyors who request information protected under the Act Register for the webinar The webinar will take place at 13:00 ET (18:00 BST)
  11. News Article
    The ambition to diagnose cancer in its earliest stages in England is “seriously off target”, according to a new report by QualityWatch, a research programme by the Nuffield Trust and The Health Foundation A rise in urgent referrals in recent years has contributed to delays, along with patients finding it difficult to raise concerns about cancer with GPs. Inequalities in diagnosis, particularly among young people, those in deprived areas, and patients from ethnic minorities, was also highlighted by researchers. Experts said that while family doctors are “highly trained” to identify cancers, the issue remains a challenge in primary care because some symptoms can be vague. The NHS Long Term Plan said the health service is aiming to diagnose 75% of cancer patients when the disease is in its early stages by 2028. However, analysis of NHS data by QualityWatch said “our current course shows we are seriously off target”. More than 320,000 people in England were diagnosed with cancer in 2021 – the equivalent of some 900 a day – the report said, with the number of urgent cancer referrals rising since 2009 to more than two million in 2020/21. Read full story Source: Medscape, 24 April 2024
  12. Content Article
    Parkinson’s is the fastest growing neurological condition in the world. It can affect young or old, and in the UK, around 145,000 people are living with the condition. With population growth and ageing, this figure is estimated to increase by 20%, within the next ten years. At the moment, there is no cure for Parkinson’s, but medication plays a vital role in managing symptoms and preventing deterioration. People with Parkinson’s face a number of specific patient safety issues when accessing healthcare including communication difficulties and risks associated with medication delays. In this blog, Patient Safety Learning has pulled together 11 useful resources about Parkinson’s shared on the hub. They include guidance for patients and their families about hospital stays and medication, and awareness-raising resources for healthcare professionals about the patient safety issues people with Parkinson’s face.
  13. Content Article
    This systematic review and meta-analysis in Surgery aimed to summarise evidence about the impact of hospital and surgeon volume on complications of emergency intra-abdominal surgery. The authors included nine cohort studies that reported outcomes for cholecystectomy, colectomy, appendectomy, small bowel resection, peptic ulcer repair, adhesiolysis, laparotomy and hernia repair. The results showed that hospital and surgeon volume was significantly associated with higher complications in patients undergoing emergency intra-abdominal surgery.
  14. Content Article
    This Lancet article highlights three challenges to measuring and analysing social determinants of health (SDoH) for which data science—a cross-disciplinary set of skills to make judgements and decisions with data by using it responsibly and effectively—can be harnessed. The three challenges the authors examine are: Data necessary for capturing the exposure of interest at multiple levels appropriately are not always available nor easy to measure. SDoH are distal to individual health outcomes compared to biomedical determinants such as comorbidities. The distal placement of SDoH in relation to health outcomes results in requires long periods of time to observe their effect.
  15. Content Article
    This study aimed to find out whether using an artificial intelligence (AI) deterioration model decreased the risk of escalations in care during hospitalisation. The study's findings suggest that use of an AI model is associated with a decreased risk of escalations in care.
  16. Content Article
    Drawing on insights from Maternal Mental Health Alliance (MMHA) Lived Experience Champions, member organisations and local contacts, this toolkit offers creative ideas and practical tools to empower individuals in shaping perinatal mental health care at a local level. The toolkit explores innovative examples of ongoing efforts to bring about this much-needed change. It contains resources relating to: Breaking barriers Demonstrating impact Making connections Sharing stories
  17. Content Article
    This improvement initiative featured in the Journal of Patient Safety aimed to examine whether the independent double check (IDC) during administration of high alert medications resulted in improved patient safety when compared with a single check process. The authors found that IDC had no impact on reported medication events compared with single checking.
  18. Content Article
    Medical errors happen all the time. They can be overlooked or they can lead to big lawsuits and settlements. But what they rarely lead to is an apology. However, increasingly, patients, families and healthcare professionals, are calling for a new approach, one that acknowledges the lasting damage that comes from a failure to address medical mistakes. In this report for US media company NPR, a Naomi and Jeff tell their story of losing their daughter Thalia to medical error following planned surgery. They report that concerns they and Thalia raised about their breathing were ignored by healthcare professionals, and Thalia died after her brain was starved of oxygen. The hospital didn't give an explanation or apology for Thalia's death.
  19. Content Article
    This systematic review in JAMA Network Open explored how much shared decision-making (SDM) is used in interventions aimed at improving cardiovascular risk management, and how it affects decisional outcomes, cardiovascular risk factors and health behaviours. The review looked at 57 randomised clinical trials that included 88,578 patients on SDM interventions for cardiovascular risk management and 1341 clinicians, SDM interventions were associated with a slight decrease in decisional conflict and an improvement in haemoglobin A1c levels.
  20. Content Article
    This practical guide from NHS Providers aims to support NHS trust board members to address health inequalities as part of their core business. It outlines why trusts should act on health inequalities, includes a vision for what good looks like, a self-assessment tool for trusts to use to determine where they are in their journey and a list of suggested objectives for board members. It covers a wide range of trust work, from operational and clinical delivery of services, to the trust’s role as an anchor institution and as an employer of NHS staff. The suggested objectives are drawn from NHS England (NHSE) policy, guidance, and good practice from the sector.
  21. Content Article
    This study examines associations of provider burnout with their perspectives on quality improvement (QI), patient experience measurement, clinic culture and job satisfaction. The authors conducted a cross-sectional provider survey about their perspectives including the single-item burnout measure. 30% of providers reported burnout and providers in clinics with more facilitative leadership reported not being burned out (compared to those reporting burnout. More pressures related to patient care and lower job satisfaction were also associated with burnout.
  22. Community Post
    This new qualitative study might be of interest to those who have experienced dental diagnostic error or diagnostic failure. It's a start in building research evidence around the harms that can be caused. Patients’ experiences of dental diagnostic failures: A qualitative study using social media (April 2024)
  23. Content Article
    This qualitative study in the Journal of Patient Safety aimed to understand the perception of dental patients who have experienced a dental diagnostic error and to identify patient-centred strategies to help reduce future occurrences. Recruiting patients via social media, the researchers conducted a screening survey, initial assessment and 67 individual patient interviews to capture the effects of misdiagnosis, missed diagnosis or delayed diagnosis on patient lives. They found that dental patients endured prolonged suffering, disease progression, unnecessary treatments and the development of new symptoms as a result of diagnostic errors. Patients believed that the following factors contributed to diagnostic errors: Poor provider communication Inadequate time with provider Lack of patient self-advocacy and health literacy. Patients suggested that future diagnostic errors could be mitigated through: improvements in provider chairside manners more detailed patient diagnostic workups improving personal self-advocacy enhanced reporting systems.
  24. Content Article
    Official data on whooping cough show that reports of suspected cases are at a 15-year high in the first three months of 2024. This article in the Pharmaceutical Journal looks at why cases are increasing, including falling rates of children receiving the childhood 6-in-1 vaccine and maternal vaccination. It outlines the symptoms of whooping cough, describes how it can be treated and includes a map identifying infection 'hot spots' in England and Wales. This article is free to read but you will need to sign up for a free Pharmaceutical Journal online account.
  25. Content Article
    Ensuring the safe and effective use of medicines is a central function of the pharmacy team. This article in the Pharmaceutical Journal outlines how pharmacists can support the implementation of the Patient Safety Incident Response Framework (PSIRF). It aims to help pharmacists: understand the role of the Patient Safety Incident Response Framework (PSIRF). understand the difference between the PSIRF and the Serious Incident Framework. Know how the PSIRF can be applied to the pharmacy profession. This content is free to access but you will need to sign up for a Pharmaceutical Journal free online account.
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