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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Data from NHS Resolution indicates that the number of claims with a primary cause of ‘Fail to warn - Informed consent’ have increased from 128 to 248 claims per year in 2011–2012 and 2021–2022 respectively. This letter in the British Journal of Surgery highlights the impact of failures in both the process and documentation of informed consent. The writers call for further research to investigate unwarranted variation in claims and develop processes to standardise and improve the quality of consent.
  2. Content Article
    In this article for the BMJ, John R Drew, an improvement and culture consultant and Meghana Pandit, chief medical officer at Oxford University NHS Foundation Trust, argue that quality improvement (QI) should be a core tenet of how healthcare organisations are run. They highlight that some of the conditions and assumptions required for QI are at odds with prevailing management practices, with staff feeling more valued and respected while going through the QI process. They discuss the following subjects and questions: QI as the basis of management When do QI and good management coalesce? So is QI just good management? How can we help leaders get on this path?
  3. Content Article
    The tragic and preventable death of Ruth Perry, headteacher at a school downgraded by an Ofsted inspection, has sparked calls for a review of regulatory oversight. While safety and quality must be assured, it’s crucial to consider the impact of regulatory inspections on the well-being of passionate workforces facing complex and challenging environments. In this blog, healthcare entrepreneur Vanessa Webb makes the case that as a potential cause of harm to staff, regulatory inspections in public services including healthcare should be subject to Health and Safety Risk Assessments. There should be a systematic process to identify hazards, evaluate the likelihood and severity of harm, and determine appropriate controls to prevent or mitigate those risks.
  4. Content Article
    This editorial in The Guardian looks at the Government's approach to relieving pressure on GPs, which involves diverting patients to other areas of primary care, including pharmacies. The article highlights potential risks and issues associated with the approach, including the workforce issues currently facing community pharmacy and the comparative lack of standards and regulations for pharmacies. It argues that the Government's approach simply moves the issue to other areas of the healthcare system, rather than dealing with the root cause of the issue facing GP surgeries—retention and recruitment.
  5. Content Article
    Designed by the Inpatient Diabetes Team at University Hospital Southampton (UHS), the DiAppBetes app for healthcare professionals aims to provide easy access to clinical guidance on managing patients with diabetes in hospital. It allows all healthcare professionals—including non-specialists—to quickly check up to date guidance on: the basics of diabetes. screening and diagnosis. type 1 diabetes guidance notes. patient assessment. complications of diabetes. patients with diabetes in a variety of scenarios, including pregnancy, about to have surgery, new to insulin, using an insulin pump and at the end of life. diabetes treatments. The app is freely available and content is generic apart from a few hospital-specific contact details. Hospitals using the Microguide platform for antibiotic guidance can reconfigure the format of the app—if they do this, hospitals should ensure that UHS is acknowledged as the original provider of the app.
  6. Content Article
    Achieving an evidence-based practice not only depends on implementation of evidence-based interventions, but also requires de-implementing interventions that are not evidence-based, also known as low-value care (LVC). This is quite a new topic and knowledge is lacking concerning how de-implementation and implementation processes and determinants might differ. This scoping review identified 10 studies describing theoretical approaches that have been used concerning de-implementation of LVC. The findings point to the need for more research to identify the most important processes and determinants for successful de-implementation of LVC, and to explore differences between de-implementation and implementation.
  7. Content Article
    This article summarises the findings of research by Healthwatch into the impact of the cost of living crisis on people's decisions about accessing health and care. The research, which surveyed 2000 adults in England, was conducted four times between October 2022 and March 2023. It suggests that people are increasingly avoiding vital health and care services due to the fear of extra costs. Examples include avoiding:   going to a dentist because of the cost of checks ups or treatment  booking an NHS appointment because they couldn’t afford the associated costs, such as accessing the Internet or the cost of a phone call  buying over the counter medication they normally rely on  taking up one or more NHS prescriptions because of the cost. Healthwatch sets out a series of recommendations, including ensuring that the support available to help with healthcare costs is communicated to those that need it.
  8. Content Article
    This report set out an infectious disease strategy for England, including new arrangements to counter old and new threats, such as radiological and chemical hazards through bioterrorism, by describing the scope of the threat posed as well as establishing the priorities for action to combat this threat. It aimed to overhaul previously fragmented systems and to place a new emphasis on communicable diseases through direct action plans, programmes to inform understanding and legislative reform.
  9. Content Article
    This is the recording of a webinar hosted by The Patients' Association, looking at how virtual wards work and patients' experiences of virtual wards. A panel answered questions about who was suitable for care on a virtual ward, how they are staffed and what happens if you're not tech-savvy. The panel was: Jono Broad, a patient leader in the southwest of England. He is a Senior Manager for Personalised Care, NHS England South West, works on patient experience, safety and quality. Emma Matthews, Regional Community Development Lead NHS England South West, Consultant Practitioner Older People and Frailty. Dr Shelagh O’Riordan, Consultant Community Geriatrician at Kent Community Health NHS Foundation Trust and Professional Adviser to the virtual ward team at NHS England. She is also Clinical Director for Frailty in East Kent and runs a large frailty virtual ward. Dr Crystal Oldman CBE, Chief Executive, The Queen's Nursing Institute. Crystal qualified as a nurse at University College Hospital, London. In 2017, Crystal was awarded a CBE in the Queen’s Birthday Honours List for services to community nursing and her leadership of the QNI. Crystal is an Honorary Professor at London South Bank University. Patients Association member, Alan Bellinger, who represents patients on the Hospital at Home programme in Hertfordshire, and is a patient representative on the Eastern Academic Health Science Network Review of Remote Monitoring.
  10. Content Article
    Probiotics 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.
  11. News Article
    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
  12. News Article
    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
  13. Content Article
    England 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.
  14. News Article
    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
  15. News Article
    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
  16. Content Article
    This 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.
  17. Content Article
    This 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.
  18. Content Article
    In 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.
  19. 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.
  20. 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.
  21. Content Article
    Dehydration 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.
  22. Content Article
    When 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.
  23. Content Article
    This 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.
  24. Content Article
    This 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.
  25. 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.
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