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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Technologies to assist with diabetes treatment and care have evolved rapidly over the past two decades. With each new innovation coming to the market, there are hopes that technologies will solve the numerous, complex issues related to diabetes. However, although it has been demonstrated that overall, these technologies—when available—bring major benefits to people living with diabetes, they do not make the condition disappear. This article in Diabetes Epidemiology and Management discusses the interconnections between technologies and diabetes distress, an often under-acknowledged consequence of the continuous demands of diabetes.
  2. Content Article
    Transformative reflection is based on the idea is that people's perspectives on the world around them change when they reflect on new experiences that challenge their world view. NHS England (NHSE) says that reflection can be hugely valuable for patient care, staff morale and for doctors themselves. In this interview, Dr Alison Sheppard, a national clinical fellow who contributed a new NHSE guide on transformative reflection, talks about what transformative reflection is and how it can be helpful for doctors.
  3. Content Article
    In the UK today, nearly 40% of the population are living in poverty because of low income. This means that nurses and midwives are likely to meet people experiencing poverty and deprivation as part of their everyday work and should be ready and able to help them access the assistance they need to overcome the associated challenges. This article in the British Journal of Nursing examines the link between financial status and people's health and wellbeing. The article includes a case study and suggestions as to how nurses and midwives can promote financial wellbeing.
  4. Content Article
    This article explains Quality and Safety Education in Nursing (QSEN), a US initiative to align nursing education and nursing best practices in quality and safety standards. The six focus areas of QSEN are: Patient-centred care Evidence-based practice Teamwork and collaboration Safety Quality improvement Informatics
  5. News Article
    The chief executive of the Royal College of Speech and Language Therapists (RCSLT) said it is "alarming" that a survey found almost 1 in 4 jobs are vacant across the UK. A survey by the professional body found speech and language therapy (SLT) vacancies across the UK had reached 23% with almost all children's services (96%) and 9 out of 10 adult services (90%) which responded saying recruitment is more or much more challenging than at any time in the past three years. A delay to receiving SLT support can affect a person's ability to communicate with friends and family or to eat and drink as well as a child's ability to access the school curriculum, to regulate their behaviour or to form friendships. The COVID-19 pandemic added to the pressure on SLT services, exacerbating waiting times for assessment and support, as well as adding referrals to see young children whose language and social development was hampered by pandemic restrictions which meant they were not mixing with other children or adults at play groups, nurseries, and schools. RCSLT's new Chief Executive, Steve Jamieson, said, "By the time they are seen by a SLT their needs are a lot more complex and difficult to manage and to treat.” Read full story Source: Medscape, 5 April 2023
  6. News Article
    Disruption caused by the coronavirus pandemic is being blamed for the first recorded rise in tuberculosis (TB) cases and deaths in Europe for two decades. Some 27,300 people died from TB in the World Health Organization’s Europe region in 2021, up from 27,000 deaths the previous year, according to a new surveillance report by WHO and European Union’s disease prevention agency. The rate of new cases and relapses in the region is also estimated to have increased by 1.2 per cent compared to 2020, in a reversal analysts said “reflects the impact of disruption to TB services caused by the Covid-19 pandemic.” The report comes days after the UK Health Security Agency (UKHSA) reported a 7.3 per cent rise in cases in England in 2021, a year that saw new 4,425 cases. Dr Esther Robinson, head of the UKHSA's TB unit, said, "Tuberculosis remains a risk to some of the most vulnerable people in our society and this data highlights that progress towards elimination has stalled." Read full story Source: Independent, 3 April 2023
  7. Content Article
    In this blog, Dr Timothy Ferris, NHS England National Director of Transformation and Rachel Power, Chief Executive at The Patients Association, look at patient access to health records. Dr Ferris writes about NHS England's ambition that patients are able to see their GP health record "at the touch of a button" and Rachel explains why it's important that patients have access to their records. Three patients also share why they find digital access to their records so useful.
  8. Content Article
    In this article for Chamber UK magazine, Lyn Brown MP warns that hysteroscopy could be the next big women's health scandal and calls for dramatic improvements in care. She describes the accounts of women being encouraged to undergo hysteroscopy without anaesthesia and appropriate pain relief, and how lack of informed consent is leaving women feeling violated and scared to undergo future gynaecological procedures. She also describes how she raised the issue in the House of Commons and outlines the failure of the Royal College of Obstetrics and Gynaecology's new 'Good Practice Paper' to properly address the decision making process and acknowledge the severity of the pain experienced by many women who undergo hysteroscopy. The article can be found on page 64 of the e-magazine.
  9. News Article
    The manufacturer of eyedrops recently linked to deaths and injuries lacked measures to assure sterility at its factory in India, according to U.S. health inspectors. Food and Drug Administration officials uncovered about a dozen problems with how Global Pharma Healthcare made and tested its eyedrops during an inspection from late February through early March. The FDA released its preliminary inspection report Monday. The company uses procedures that can’t actually ensure its products are sterile, FDA staff wrote. In particular, the inspectors found that the plant had used “a deficient manufacturing process” between December 2020 and April 2022 for products that were later shipped to the US. The plant in India’s southern Tamil Nadu state produced eyedrops that have been linked to 68 bacterial infections in the U.S., including three deaths and eight cases of vision loss. Four people have had their eyeballs surgically removed due to infection. The drops were recalled in February by two U.S. distributors, EzriCare and Delsam Phama. In a statement, the FDA's Jeremy Khan wrote, “We urge consumers to stop using these products which may be harmful to their health.” Read full story Source: NBC News, 4 April 2023
  10. Content Article
    This paper, published by the National Bureau of Economic Research (NBER) aimed to explore how parental wealth and race affect maternal and infant health outcomes in California. The authors used administrative data that combines the California birth records, hospitalisations and death records with parental income from Internal Revenue Service tax records and the Longitudinal Employer-Household Dynamics file to provide new evidence on economic inequality in infant and maternal health. The paper also used birth outcomes and infant mortality rates in Sweden as a benchmark, finding that infant and maternal health is worse in California than in Sweden for most outcomes throughout the entire income distribution.
  11. News Article
    A former nursing home manager has been fined £40,000 after pleading guilty to two offences of failing to provide safe care and treatment to two residents at Rossendale Nursing Home in Lancashire. Caroline Taylforth, who established her first residential care home in 1997, was prosecuted by the CQC. She was the registered manager at Rossendale Nursing Home at the time of the incidents, and admitted mistakes she had made that meant two residents did not receive safe care and treatment, and resulted in "avoidable harm" while in her care, said a CQC spokesperson. The first offence was for failures in the care of resident Patricia Sutton, aged 77, who was admitted to the home on 11 October 2018 and had a significant medical history. On 6 November 2019, Patricia Sutton was eating dinner in the dining room and started choking. She was taken to hospital and died later that day. Ms Sutton had previously been involved in three other choking incidents and should have been referred to a speech and language therapist after the second one occurred to properly assess the risks, said the CQC. However, Ms Taylforth "did not safely assess, monitor or manage the risk or make this referral", the CQC concluded. The CQC also prosecuted Ms Taylforth for another incident concerning Dereck John Chapman, aged 82, who was admitted to the home on 22 October 2019 with multiple health issues and was also prone to having falls. Following admission to the home, Mr Chapman suffered at least 14 falls. Ms Taylforth "failed to mitigate" the risk of falls and "failed to ensure" Mr Chapman was promptly referred to appropriate services, such as the falls team, GP, and local authority following known incidents, particularly those resulting in injuries, criticised the CQC. Read full story Source: Medscape, 6 April 2023
  12. News Article
    A scandal-hit children’s mental health hospital set to close after an investigation uncovered allegations of severe abuse could reopen within months due to a legal loophole, it can be revealed. Taplow Manor hospital, in Maidenhead, will shut in May after the Independent exposed claims of “systemic abuse” and poor care from more than 50 former patients. Police are currently carrying out two investigations into the hospital–one into a patient death and a second into the alleged rape of a child involving staff. Active Care Group, which runs the hospital, announced last week that would close but in letters sent to staff since then, it said it was looking to retrain them with plans to “reopen as an adult acute service” in a matter of months. A loophole in the regulations means that there is nothing to stop healthcare providers from applying to the watchdog, the Care Quality Commission, to reopen, even if serious concerns have been raised about the closed operation. Read full story Source: Independent, 4 April 2023
  13. Content Article
    Improving medication safety during transitions of care is an international healthcare priority. While existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy. This study in the journal Therapeutic Advances in Drug Safety aimed to characterise the nature and contributory factors of medication-related incidents during transitions of care from secondary to primary care. The authors found several themes for future research that could support the development of interventions, including: commonly observed medication classes older adults increase patient engagements improve shared care agreements for medication monitoring post hospital discharge.
  14. Content Article
    In this joint statement, National Voices, a coalition of health and social care charities in England, supported by 82 charities and professional bodies, call on the Government to act on the serious challenges faced by the NHS and social care workforce, which it states are badly impacting upon people’s experience of health and care. Patient Safety Learning is one of the signatories of this statement.
  15. News Article
    Nurses and physiotherapists can now provide ill patients with “fit-notes” to stay off work in an attempt to ease pressure on GP services. A range of health staff including pharmacists and occupational therapists are certifying illness sign-offs under moves to free up doctors to tackle the treatment backlog. NHS Grampian has successfully completed a pilot scheme at a GP practice which staff described as “really positive” and a step in the right direction. David Cooper, a GP from Old Machar Medical Practice in Aberdeen, said: “It is a more efficient way for us to work as a practice. For the nurses, physiotherapists and others who are working closely with a patient, it makes sense for them to be able to work on fit-notes without having to refer back to a GP for sign off. “We have found it works particularly well for those with chronic, long-term conditions or illness and the process behind the scenes is also now electronic so it saves paper, time and energy.” Paul Gray, a physiotherapist at Old Machar, said: “It makes the patient’s journey easier and it is better for people to access them from those who are assessing your physical capabilities." Read full story (paywalled) Source: The Times, 6 April 2023
  16. Content Article
    In this article, critical criminologist Sharon Hartles looks at the ongoing fight for justice by families affected by the hormone pregnancy test (HPT) Primodos. Primodos was given to thousands of women in the 1960s and 70s which has been linked to miscarriages, birth defects and stillbirth. The Department of Health and Social Care (DHSC) and pharmaceutical company Bayer are applying to strike out court proceedings against them in a civil litigation case brought by the Association for Children Damaged by Hormone Pregnancy Tests (ACDHPT). This would prevent a five-day hearing scheduled to take place at the Royal Courts of Justice in May 2023 from going ahead. The article outlines the argument brought by the DHSC and Bayer that no additional evidence has been found to warrant the case being brought by the ACDHPT. It then goes on to highlight recent research that has established a causal link between HPTs and birth malformations and that therefore gives credence to the litigation. Sharon highlights the importance of the legal system acknowledging and confronting the damage inflicted upon the families affected by the use of Primodos, many of whom have been seeking justice for decades. Related reading Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response (Sharon Hartles, August 2021) Sodium Valproate: The Fetal Valproate Syndrome Tragedy A year on from the Cumberlege Review: Initial reflections on the Government’s response (Patient Safety Learning, 23 July 2021)
  17. News Article
    Just three years of breathing polluted air can increase a person’s risk of lung cancer, a study has found. Scientists have found, for the first time, the mechanism that proves air pollution causes lung cancer to develop. Research funded by Cancer Research UK and conducted by the Francis Crick Institute showed that small pieces of carbon particulates, known as PM2.5, enter deep into the lungs and lead to tumour development. A key gene, known as EGFR, mutates and then the presence of the air pollution exacerbates the growth and expansion of these mutated cells, the study found. The scientists are hopeful that by shedding light on how lung cancer develops they can help to prevent it. Prof Charles Swanton, the chief clinician for Cancer Research UK and lead investigator on the study, said a statin-like drug to protect against lung cancer and ensure the inflammation that can lead to the disease is kept under control could be developed in as little as 10 years. Prof Swanton said: “Our study has fundamentally changed how we view lung cancer in people who have never smoked." Read full story (paywalled) Source: The Telegraph, 5 April 2023
  18. News Article
    Lives could be saved by a new tool that identifies those most at risk of developing lung cancer, according to researchers. The CanPredict tool can spot those most at risk of developing the disease over the next decade and put them forward for screening tests earlier, researchers from the University of Oxford and the University of Nottingham said. They created and tested CanPredict using the anonymised health records of more than 19 million adults from across the UK and hope it can save “time, money and, most importantly, lives”. Lung cancer is the leading cause of cancer deaths worldwide and the second most common form of the disease, but early diagnosis has been shown to improve survival rates. Professor Julia Hippisley-Cox, senior author and professor of clinical epidemiology and general practice at the Nuffield Department of Primary Care Health Sciences, University of Oxford, said: “We hope that this new validated risk tool will help better prioritise patients for screening and ultimately help spot lung cancer earlier when treatments are more likely to help. We’d like to thank the many thousands of GPs who have shared anonymised data for research without whom this would not have been possible.” Read full story Source: The Independent, 6 April 2023
  19. News Article
    An independent group overseeing the reviews into a toxic culture at University Hospitals Birmingham have raised concerns over a possible ‘cover up’ of key reports. The cross-party reference group, which includes MPs, council and Healthwatch officials, has demanded transparency over key decisions, and says there are continuing concerns over the trust’s leadership. It has been scrutinising a review into patient safety concerns at UHB, which found the trust’s executive had become “overzealous and coercive”. On the day this review was released, it was revealed that UHB’s former CEO David Rosser had decided to retire. The group, chaired by MP Preet Gill, said in a statement: “The allegations made by whistleblowers were not isolated incidents, but the result of a deep-seated and toxic culture. While Dr Rosser has recently announced his retirement, one member of staff, albeit a chief executive, cannot be responsible for this alone. Feedback from staff has made it clear that there must be collective accountability by the senior leadership for the distressing culture afflicting the trust." Read full story (paywalled) Source: HSJ, 5 April 2023
  20. News Article
    Some of the most vulnerable patients could risk missing out on covid treatment because new rules will place the onus on them to access antiviral medication themselves instead of the NHS contacting them directly, senior figures have warned. The warnings follow NHS England’s national medical director Sir Stephen Powis writing to local leaders last week advising them the national commissioner will no longer identify patients who are eligible for covid treatment. This means eligible patients will need to contact local services themselves, rather than being approached proactively by a covid medicines delivery unit. Patients Association chief executive Rachel Power said: “Expecting patients ill with covid to know they’re eligible for these treatments and ask for them is unreasonable. How will they know they’re eligible or who to contact?” Read full story (paywalled) Source: HSJ, 6 April 2023
  21. Content Article
    The Healthcare Safety Investigation Branch (HSIB) will transition into new arms-length body The Healthcare Services Safety Investigation Body (HSSIB) in October 2023. In this article, HSSIB's Chair Designate, Ted Baker, reflects on: how the Francis Inquiry was instrumental in changing the view of patient safety in the NHS. the role of HSIB over the last five years in identifying systemic causes of patient harm. what the future holds for HSSIB.
  22. Content Article
    This report outlines the results of the Patient Information Forum's (PIF's) 2022 survey and sets out progress made in the crucial areas of health and digital literacy since the Covid-19 pandemic.
  23. Content Article
    The overall goal for the Quality and Safety Education for Nurses (QSEN) project is to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes necessary to continuously improve the quality and safety of the healthcare systems they work in. This webpage outlines the competencies in the QSEN competency framework: Patient-Centered Care Teamwork and Collaboration Evidence-based Practice (EBP) Quality Improvement (QI) Safety Informatics
  24. News Article
    The parents and children of victims of the contaminated blood scandal should receive government compensation, a judge has said. The chairman of the infected blood public inquiry, Sir Brian Langstaff, said it was time to "recognise deaths which have so far gone unrecognised". More than 3,000 people died after contracting HIV or hepatitis C via NHS treatments in the 1970s and 80s. The government must now respond to the recommendations. In August 2022, the government agreed to make the first interim compensation payments of £100,000 each to about 4,000 surviving victims, and bereaved widows. Sir Brian said, "It is a fact that around 380 children with bleeding disorders were infected with HIV. Some of them died in childhood. But their parents have never received compensation. Children who were orphaned as a result of infections transmitted by blood transfusions and blood products have never had their losses recognised. It's time to put that right." Read full story Source: BBC News
  25. News Article
    Delays in people leaving hospital in England could be costing an average of £395 per night, according to researchers at a health think tank. The direct costs of delayed discharges, where patients are considered medically fit to leave hospital, is estimated to be around £1.89 billion for the past financial year, the King's Fund said. This estimate does not count extra costs, including cancelled operations or staff time spent arranging care packages. Ambulance handover delays are often linked to a shortage of space caused by people who no longer need to be in hospital beds. The most recent PA analysis of NHS figures showed an average of 13,300 beds per day in the week to March 26 were filled by people ready to be discharged, compared with 12,643 at that point last year. Overall, 42% of medically fit patients in England were discharged, though the rate varied between regions, from 31% in the North West to 52% in eastern England. Read full story Source: Medscape, April 2023
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