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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This guide published by NHS England & Improvement describes the validation rules relating to the LFPSE project, specifically around submitting an Adverse Event via the Adverse Event Application Programming Interface (API). It covers several types of validation rules, which have been split into three sections. Bespoke business validation rules which have been implemented based on the dependencies between responses and extensions that cannot be captured by the FHIR resource validation. FHIR validation responses which may be returned from the API when native FHIR validation checks the submission body against the LFPSE FHIR profiles defined for an adverse event. Invalid operations and similar responses which are external to validation of the submission, including responses pertaining to permissions, personal information and any other responses that do not fit into the two categories above.
  2. Event
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    This popular training day covers the must do’s and the grey areas around the statutory Duty of Candour, with a strong emphasis on going beyond mere compliance and delivering the duty of candour in a meaningful way for patients and families and for the staff involved and the organisation. It has been updated to directly support the successful implementation of the PSIRF guidance and the ‘Harmed Patient Pathway’. The training is delivered by Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. Prices £245 (plus vat) per person Discounted rate for bookings of 3 or more: £220 (plus vat) per person Book a place Watch introductory video about the course
  3. News Article
    Roughly three in 10 adults have been addicted to opioids or have a family member who has been, and less than half of those with a substance use disorder have received treatment, according to a new survey conducted by KFF, a health policy research group. The survey, which polled more than 1,300 adults in July, underscores the broad and often harmful influence of opioid addiction across the nation, which recorded around 110,000 fatal drug overdoses last year alone. And the findings suggest that some proven medications for helping curb drug cravings, such as buprenorphine and methadone, are still not getting to those who need them. Only 25 percent of participants in the poll who said they or someone in their family had an opioid addiction reported receiving medication for themselves or family members. Mollyann Brodie, the executive director of KFF’s polling program, said that the numbers might be an undercount, as some survey participants might have been hesitant to share histories of opioid addiction. Addiction cuts across class, race and geography, the KFF researchers found. Rural and white Americans were the likeliest to report personal or family opioid addiction, but significant percentages of Black, Hispanic, urban and suburban families did, as well. White families were more likely than Black or Hispanic families to say that they had received treatment. Overdose fatality rates among Black Americans have climbed substantially in recent years, the Centers for Disease Control and Prevention found in a study last year. Dr. David Fiellin, an addiction physician at the Yale School of Medicine, said the survey showed the need for a stronger federal response to substance use disorders, akin to the one for AIDS. He said, “There’s often a misunderstanding of what treatment actually looks like and what it is—people often look to a quick fix,” he said, referring to a detox strategy. “Effective treatment tends to be much more long term and requires addressing the denial that can be part of the condition.” Read full story (paywalled) Source: New York Times, 15 August 2023
  4. News Article
    Young people who vape are more at risk of bronchitis and shortness of breath, research has suggested, even if they also smoke cigarettes. Researchers from the US tracked the respiratory health of young people in the Southern California Children’s Health Study between 2014 and 2018. They conducted surveys which asked about people’s vape and cigarette use in the last 30 days. Researchers also included questions on bronchitic symptoms, such as a daily cough for three months in a row, as well as wheezing and shortness of breath. The study found the odds of wheezing were 81 per cent more likely among past 30-day e-cigarette users than among “never users”. The odds of bronchitic symptoms were twice as likely, while those of shortness of breath were 78 per cent more likely after accounting for survey wave, age, sex, race and parental education. The researchers said their findings contribute to “emerging evidence from human and toxicological studies that e-cigarettes cause respiratory symptoms that warrant consideration in regulation of e-cigarettes.” Jon Foster, policy manager at Asthma + Lung UK, said it is “interesting” the study found a link between vaping and lung conditions in young people, but pointed out the regulation around the amount of nicotine and chemicals used in e-cigarettes is “much tighter” in the UK than the US. “More research would be needed to find out if the situation in the UK is the same,” he added. “However, given that we still know little about long-term effects, the growing popularity of vaping among children and young people is concerning.” Read full story Source: Independent, 16 August 2023
  5. News Article
    Updated Covid vaccines are expected to become available in the US next month as alarm grows over a new variant dubbed Eris. Healthcare providers are grappling with a rise in hospitalisations stemming from Covid infections. Eris or EG.5.1, a subvariant of Omicron that originally emerged in late 2021, now accounts for around 17per cent of current COVID cases, according to the CDC. Symptoms of the new variant include a runny nose, headache, fatigue, sneezing and a sore throat. In the week of 30 July to 5 August, the latest period that data is available for, hospitalisations spiked by more than 14per cent, while deaths rose 10per cent compared to the previous week. It comes as providers and pharmacies prepare to roll out an updated vaccine designed to combat Omicron — but experts are not very optimistic that the greater majority of Americans will opt to be vaccinated. Fewer than 50 million people in the US got the shot last fall, compared to 250 million, or 73 per cent of the country’s population, when the vaccine was first made available in 2021, according to the agency. Read full story Source: Independent, 16 August 2023
  6. News Article
    Record numbers of people have been hospitalised with heart attacks in the wake of the pandemic, official figures show. On Tuesday, health chiefs will launch a campaign urging those with symptoms to seek help, with fears that too many cases are being detected too late. The new figures for England show that more than 84,000 patients were admitted to hospital because of a heart attack in 2021/22 – a rise of more than 7,000 in a year. It follows warnings that heart deaths have risen by more than 500 a week since the first lockdown, with a fall in the numbers prescribed vital medication amid struggles to access GP care. Health officials are afraid that people are still failing to come forward, adding to the collateral damage caused by the pandemic. From this week, an NHS advert will encourage people to call 999 as soon as they experience symptoms of a heart attack, such as squeezing across the chest, sweating and a feeling of uneasiness, so people have the best chance of survival. Prof Nick Linker, a cardiologist and NHS national clinical director for heart disease, said: “Cardiovascular disease causes one in four deaths across the country, so it is vital that people are aware of the early signs of a heart attack. Every moment that passes during a heart attack increases heart muscle damage, and nearly all of the damage takes place within the first few hours, so if you experience symptoms such as a sensation of squeezing or tightness across the chest alongside sweating, nausea, or a sense of unease, please call 999 so you have the best chance of a full recovery”. Read full story (paywalled) Source: The Telegraph, 15 August 2023
  7. News Article
    Patients with cancer symptoms could bypass their GP in the future and go straight for a scan, the health secretary has suggested, in the latest “radical” attempt by the government to cut huge NHS waiting lists. The suggestion, which comes as the government is expected to reduce the number of NHS cancer waiting time targets, could form part of proposals to “design out bottlenecks” in the NHS system, Steve Barclay said in an interview. Health department officials are reportedly working on proposals that would mean some patients experiencing cancer symptoms could go straight to an NHS diagnostic centre – or “one-stop shop” – without a GP referral. “We are very much looking at those patient pathways,” Barclay told the Daily Telegraph. “Where there are bottlenecks in the system of referral from the GP, is there scope to go direct to the relevant diagnostic test or to the clinician? Breast cancer is a good example because almost always the GP refers on … and therefore there’s an opportunity to design out bottlenecks in the system.” Read full story Source: Guardian, 16 August 2023
  8. 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
  9. 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.
  10. 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?
  11. 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.
  12. 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
  13. 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
  14. 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.
  15. Event
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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
  16. 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
  17. 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
  18. 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
  19. 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
  20. 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
  21. 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
  22. 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
  23. 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.
  24. 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.
  25. 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
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