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Content ArticleProbiotics are used for both generally healthy consumers and in clinical settings, but there have been adverse events as a result of their consumption. Concise and actionable recommendations on how to use probiotics safely and effectively are therefore needed, especially as increasing numbers of new strains and products come to market, and probiotic use increases in vulnerable populations. The International Scientific Association for Probiotics and Prebiotics convened a meeting to discuss and produce evidence-based recommendations on potential acute and long-term risks, risks to vulnerable populations, the importance for probiotic product quality to match the needs of vulnerable populations and the need for adverse event reporting related to probiotic use. This paper presents these recommendations to guide the scientific and medical community on judging probiotic safety.
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News Article
Almost 780,000 on NHS Scotland waiting lists
Patient-Safety-Learning posted a news article in News
Almost 780,000 Scots found themselves on an NHS waiting list for an appointment, treatment, or test, new figures show. Statistics published on Tuesday by Public Health Scotland show a rise in the number of people waiting, from 772,887 on December 31 to 779,533 as of March 31. Some 479,725 people were waiting for an outpatient appointment on March 31, an increase of 0.5% (2,617) from December 31 and 14.5% higher than the same date last year. Since March 2020 – the beginning of lockdowns in response to the pandemic in the UK – the waiting list has grown by 87%. A Scottish Government target aims to ensure 95% of patients are seen within 12 weeks. Of those waits, 31,498 people had been waiting longer than 1 year for their procedure, the figures show. Humza Yousaf, Scotland's First Minister said: "There’s going to be a long way to go. The recovery plan is purposely a 5-year recovery plan because we know that recovery from the pandemic—which was the biggest shock the NHS faced for almost 75 years—is going to take us not weeks or months, but years to recover from." Read full story Source: Medscape, 31 May 2023 -
News Article
Why the Met shouldn’t stop responding to mental health 999 calls
Patient-Safety-Learning posted a news article in News
Sir Mark Rowley, commissioner of the Metropolitan Police, has written to health leaders warning the force will stop sending officers to attend thousands of 999 calls about mental health incidents. The ban will only be waived if a threat to life is feared. The move by Scotland Yard follows the rollout of a similar policy by Humberside Police in 2020 called Right Care Right Person, which sees mental health professionals dealing with calls. An inspection by His Majesty’s Inspectorate of Constabulary, Fire and Rescue Services in November found the switch had saved the force – which has mental health workers from the charity Mind in the force control room – 1,100 police hours per month. However, there is a concern that healthcare services cannot possibly set up an appropriate response that will keep vulnerable individuals safe within three months. Read full story Source: Independent, 31 May 2023 -
Content ArticleEngland is the only country in the UK to still charge patients for prescriptions, with charges having been abolished in Wales and Scotland in 2007 and 2011, respectively. However, for patients in England, the cost is rising; in March 2023, the government announced an inflationary increase of 3.21%, bringing the prescription charge up to £9.65. And the number of people eligible to pay could increase, following government proposals to raise the upper age exemption for free prescriptions from 60 to 65 years. This article looks at the impact of prescription charges on health inequalities, particularly focusing on the impact of the cost of living crisis. The reporter speaks to pharmacists who regularly see patients making difficult choices about which prescriptions to collect, as well as highlighting research that suggests many patients with long term conditions are forgoing their medications as they cannot afford them.
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News Article
Paediatric wards may not be safe for patients with 'high-risk' behaviours
Patient-Safety-Learning posted a news article in News
Children presenting with 'high-risk' behaviours are being cared for in NHS paediatric wards that may put them and others at risk of harm, according to a new report from the Healthcare Safety Investigation Branch (HSIB). HSIB's interim report warns that the placement of children and young people with complex mental health issues on NHS paediatric wards can impact on the wellbeing of these patients and their families, and pose a risk to other patients and staff. The report emphasises that paediatric wards are designed to care for patients who only have physical health needs and not for those who are exhibiting high-risk behaviours, which include attempts to die by suicide, self-harm, attempts to leave the hospital without permission, and episodes of violence and aggression. Examples of children and young people being restrained or sedated in front of other sick and vulnerable patients, families feeling concerned for their and their children's safety during incidents, rooms being stripped down to remove any risk of self-harm or death by suicide, and paediatric staff being physically assaulted are cited in the report. Saskia Fursland, HSIB national Investigator, said,"We know that NHS staff are trying to provide a safe environment for their patients, but they are facing difficult choices in wards that are not designed to support children and young people displaying high-risk behaviours. Our ongoing investigation will take a longer-term look at effective design, adaptations and risk management in the wards. A whole system response is now needed to ensure we can keep children and young people safe." Read full story Source: Medscape, 25 May 2023 -
News Article
Health alert system aims to cut heatwave deaths
Patient-Safety-Learning posted a news article in News
A new alert system will warn the public when high temperatures could damage their health this summer in England. Run by the UK Health Security Agency and the Met Office, it is aimed at reducing illness and deaths among the most vulnerable as climate change makes heatwaves more frequent. The Heat Health Alert system will operate year-round, but the core alerting season will run from 1 June to 30 September. The system will offer regional information and advice to the public and send guidance direct to NHS England, the government and healthcare professionals. Individuals can sign up to receive alerts directly and people can specify which region they would like to receive alerts for. Dr Agostinho Sousa, head of extreme events and health protection at the UK Health Security Agency, said, "It is important we are able to quantify the likely impacts of these heatwaves before they arrive to prevent illness and reduce the number of deaths." Read full story Source: BBC News, 1 June 2023 -
Content ArticleThis study in BMJ Open Quality aimed to assess the patient safety status in selected hospitals in Ghana. The authors concluded that the current patient safety status in the hospitals in the study was generally good, with the highest score in the knowledge and learning in the patient safety domain. Patient safety surveillance was identified as the weakest action area.
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Content ArticleThis BMJ article by journalist Andrew Kersley reports on a meeting of 157 medical experts and academics held at the Royal Society of Medicine on poverty and the cost-of-living crisis, which took place in May 2023. One academic at the event warned that the long term effect of ongoing economic inequality on life expectancy was worse than six unmitigated covid pandemics. The three solutions proposed at the meeting that received the most support were: a national strategy to tackle poverty the nationwide delivery of “more affordable, quality, secure social and rental housing” urgently increasing the rate of Universal Credit as well as removing the restrictions related to total benefits and multiple children.
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Content ArticleIn Australia, as in many other countries, the harms caused by transvaginal mesh surgery have prompted individual and collective attempts to achieve redress. Media outlets covered aspects of the rise of mesh surgery as a procedure, the experience of mesh-affected women and the formal inquiries and legal actions that followed, The authors of this article in the journal Health Expectations conducted a media analysis of the ten most read Australian newspapers and online news media platforms, focusing on how mesh and the interaction of stakeholders in mesh stories were presented to the Australian public. They found that mass media reporting, combined with medicolegal action and an Australian Senate Inquiry, appears to have provided women with greater epistemic justice, with powerful actors considering their stories. They argue that although medical reporting is not recognised in the hierarchy of evidence embedded in the medical knowledge system, in this case, media reporting has contributed to shaping medical knowledge in significant ways.
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Content Article
An understanding of the social sciences within infection prevention and control (IPC) is important for those working in health and social care. This new book positions the specialty of IPC as more than a technical discipline concerned with microbes. It is about people and their behaviour in context and the book therefore explores a number of relevant social sciences and their relationship to IPC across different contexts and cultures. IPC is relevant to every person who works in, and accesses health care and it remains a global challenge. Exploring novel approaches and perspectives that expand our collective horizons in an ever changing and evolving IPC landscape therefore makes sense. -
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. Maureen discusses the important role of professional standards in building a patient safety infrastructure, the need to reframe safety as a positive idea and her experience of implementing learning processes during her time as a GP. -
Content ArticleDehydration can be a significant risk to people taking certain medicines. These Sick Day Rules cards aid patients in understanding the medicines they should stop taking temporarily during illness which can result in dehydration, such as vomiting, diarrhoea and fever. They are intended for use as a tool to support conversations between healthcare professionals and patients about their medicines and dehydration.
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Content ArticleWhen people don't feel their actions will make a difference because of the vast scale of a problem, they are less likely to act, and this has implications for attempts to improve patient safety and reduce avoidable harm. In this article, Brian Resnick, science and health editor at Vox, interviews psychologist Paul Slovic, who has been researching human responses to risk and compassion since the 1970s. They discuss the psychological impact of large numbers of people on our ability and willingness to respond compassionately and to act on that compassion. They look at Slovic's research into the concepts of psychic numbing and the prominence effect, focusing on the global refugee crisis and why individuals and governments fail to act in the face of immense suffering.
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Content ArticleThis study in the Journal of Patient Safety outlines the development of the Leapfrog composite patient safety score. The researchers aimed to develop a composite patient safety score that provides patients, healthcare providers and healthcare purchasers with a standardised method to evaluate patient safety in general acute care hospitals in the United States. The study concluded that the composite score reflects the best available evidence regarding a hospital’s efforts and outcomes in patient safety.
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Content ArticleThis study in the Journal of Patient Safety and Risk Management aimed to assess the patient safety situation in Ghana across the World Health Organization's (WHO’s) 12 action areas of patient safety. The authors used interviews and observation including a WHO adapted questionnaire across 16 selected hospitals, including two teaching hospitals selected from the northern and southern parts of the Ghana. The key strength identified in the patient safety situational analysis was knowledge and learning in patient safety, while patient safety surveillance was the weakest action area identified. There were also weaknesses in areas such as national patient policy, healthcare associated infections, surgical safety, patient safety partnerships and patient safety funding.
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Content Article
The Community Health and Wellbeing Worker (CHWW) model was devised in Brazil in the 1990s, where it is called the Family Health Strategy. There are over 250,000 CHWWs in Brazil, described as ‘the ears and eyes of the GP in the community’. They are full time members of the local primary care team and focus on a defined location, usually 200 households, keeping in regular contact with the residents. By visiting households at least once a month, the delivery of primary care becomes truly local and embedded into everyday life. This article describes a pilot of a CHWW model by the NIHR Applied Research Collaboration Northwest London. It discusses how the project was established and includes case studies from the pilot. -
Content ArticleIn this blog, After Action Review (AAR) specialist Judy Walker shares an account of a successful AAR that took place amongst a surgical team. The AAR was called after a near-miss where the anaesthetist was prevented from injecting spinal block medication into the wrong side of a patient's spine by an operating department practitioner (ODP). The story demonstrates the benefits of AAR, including accelerated learning, a no-blame approach, flattening staff hierarchy and a significant reduction in the time it takes to investigate an incident.
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Content Article
D1abasics campaign resources (UHS, May 2023)
Patient-Safety-Learning posted an article in Diabetes
People with diabetes account for one in three hospital inpatients, and this is projected to increase to one in five in the next few years. Often, people are in hospital for reasons other than their diabetes, so it is important that staff across all specialties understand the basics of diabetes care in order to ensure patient safety. D1abasics is an innovative project that aims to equip all healthcare professionals to support the basic diabetes healthcare needs of their patients. Developed by the diabetes team at University Hospital Southampton with funding and support from the charity Diabetes UK, the campaign includes resources such as posters, lanyards and prompt cards. The diabetes team is supporting learning across the hospital by making visits to all wards and specialties to promote D1abasics. You can download the D1abasics poster below. -
Content Article
The term 'Gemba Walk' is derived from the Japanese word 'Gemba' or 'Gembutsu' which means 'the real place', so it can be literally defined as the act of seeing where the actual work happens. A safety Gemba Walk, or Gemba safety walk, is a safety walk integrated with the Gemba method, emphasising the continuous improvement of safety by watching the actions required to complete daily tasks and determine ways to make work safer. While a typical site safety walk through aims to maintain compliance with safety standards, a safety Gemba Walk focuses on looking for opportunities to continuously improve workplace safety. This article describes the Gemba Walk method and includes information on: What is a Safety Gemba Walk? What is a Virtual Gemba Walk? Why are Gemba Walks important? Benefits How to do a Gemba Walk Process How often should you do a Gemba Walk? Effective ways to do a Gemba Walk Examples -
Content ArticleThis mixed-methods study in the Journal of Multidisciplinary Healthcare examined how health staff in Indonesian hospitals perceived open disclosure of patient safety incidents (PSIs). The authors surveyed 262 health workers and interviewed 12 health workers. In the quantitative phase they found a good level of open disclosure practice, a positive attitude toward open disclosure and good disclosure according to the level of harm. However, in the qualitative phase they found that most participants were confused about the difference between incident reporting and incident disclosure. The authors concluded that a robust open disclosure system in hospitals could address several issues such as lack of knowledge, lack of policy support, lack of training and lack of policy. They also suggest that the government should develop supportive policies at the national level and organise initiatives at the hospital level in order to limit the negative implications of disclosing situations.
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Content ArticleThe Department of Health and Social Care is seeking views and ideas on how to prevent, diagnose, treat and manage the six major groups of health conditions that most affect the population in England. These are: cancers cardiovascular disease, including stroke and diabetes chronic respiratory diseases dementia mental ill health musculoskeletal disorders The views and ideas gathered will inform the priorities and actions in the major conditions strategy. The consultation will close at 11:59pm on 27 June 2023.
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Content ArticleThis report by The King's Fund is part of new research project that explores how NHS providers and integrated care systems (ICSs) are approaching inclusive recovery. It highlights that in 2022, people in the most deprived areas were twice as likely to be waiting more than a year for elective care compared to people in the least deprived areas. The report explores three big questions health and care leaders should be asking themselves and their teams about inequalities in their elective backlog:How are we measuring inequalities and whyDo we know why inequalities existHow will we know if things are improving?
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Content ArticleOn paper, a GP’s working schedule can look quite inviting: consulting for three and a half hours in the morning, with a coffee break in the middle, then a gap for lunch and home visits before a similar length afternoon surgery. However, this is rarely the reality for NHS GPs. In this BMJ opinion piece, GP Helen Salisbury talks about what working life is really like for GPs and highlights the mismatch between their scheduled hours and tasks and the reality, which often involves them doing much more. She highlights how the unrealistic demands GPs face have been exacerbated by a movement of work from secondary to primary care, and argues that this is contributing to the workforce crisis that general practice faces.
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Content ArticleThis is the first national ambulance volunteering strategy, produced by the Association of Ambulance Chief Executives. It recognises the important role volunteers play in the ambulance service and outlines a national approach to volunteering that will be adopted between January 2023 and May 2024. The strategy covers mission, vision, principles and measures of success.
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Content ArticleAn NHS-Led Provider Collaborative is a group of providers of specialised mental health, learning disability and autism services who have agreed to work together to improve the care pathway for their local population. They will do this by taking responsibility for the budget and pathway for their given population. The Collaborative will be led by an NHS Provider who remains accountable to NHS England and NHS Improvement for the commissioning of high-quality, specialised services. These Collaboratives aim to ensure that people with specialist mental health, learning disability and autism needs experience high quality, specialist care, as close to home as appropriately possible. They seek to enable specialist care to be provided in the community to prevent people being in hospital if they don’t need to be, and to enable people to leave hospital when they are ready. This webpage explains the role of NHS-Led Provider Collaboratives and includes case studies that demonstrate how they are helping to transform specialised mental health services.
