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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. News Article
    No new Ebola infections have been detected in Uganda for 42 days, and so on Wednesday, the World Health Organization and the Ugandan Ministry of Health officially declared that the country’s most recent outbreak of the deadly virus is at an end. Since the outbreak was officially recognised on September 20, 164 people have had confirmed or probable Ebola infections; there 55 deaths confirmed by lab testing, with another 22 deaths suspected of being caused by the virus. Those who have recovered from the virus will receive ongoing support and will be closely monitored to help scientists understand the long term impacts of the Sudan strain of the virus, for which there are currently no treatment or prevention options. The Ugandan government has also set a goal of finally identifying the animal reservoir for Ebola. Read full story Source: CNN, 11 January 2023
  2. News Article
    An inspection of a hospital has found all wards were understaffed, while ‘tearful [and] exhausted’ clinicians raised patient safety concerns to the Care Quality Commission (CQC). The CQC’s visit to Colchester hospital, run by East Suffolk and North East Essex Foundation Trust, also found patients going unfed because of low staffing ratios and patient confidentiality concerns. The concerns were raised in a letter sent by the CQC to the trust, which also runs Ipswich hospital, ahead of publication of an inspection report for older people’s medical services, which is due later this month. The CQC’s letter, published in board papers for a meeting on Thursday, said: “All wards’ actual staffing levels and skill mix meant staff were often overstretched. All staff we spoke with expressed concern about the impact on patient care and personal wellbeing. Some staff we spoke with were tearful, reported feeling exhausted and concerned that they were unable to care for patients well enough to keep them safe.” The letter also said significant positives were found. Inspectors “found staff to be welcoming, hardworking and supportive of each other… We found staff at all levels working together with the aim of putting the patients first and providing a safe and effective service”. Read full story (paywalled) Source: HSJ, 11 January 2023
  3. News Article
    The Care Quality Commission (CQC) has sounded the alarm over a “concerning decline” in women’s experiences with maternity services. Fewer women feel they always got the help they needed during labour and birth, many were disappointed at the amount of time their partners could stay with them after the delivery of their babies, and a significant number reported that they did not feel listened to when they raised concerns. The CQC said it has noticed a “deterioration” over the last five years in the ratings women gave their care. It came as a major new national poll showed a “statistically significant downward trend” on most measures examined to track maternity care across the country. In particular, concerns were raised about staff availability, confidence and trust, as well as kindness and understanding of staff. Ratings also tumbled for whether women felt they had been treated with dignity and respect, the amount of information provided to mothers, and their concerns about being listened to. Victoria Vallance, from the CQC, said: “These results show that far too many women feel their care could have been better. This reflects the increasing pressures on frontline staff as they continue in their efforts to provide high-quality maternity care with the resources available.” Read full story Source: The Guardian, 11 January 2023
  4. Content Article
    These practical guides from NHS England are suitable for those working at all levels in the health service, from ward to board. They provide information on how to make better use of data. Guides include: Making data count - getting started Making data count - strengthening your decisions
  5. News Article
    Black patients wait up to six months longer for an organ transplant than the general population, new NHS data shows. The best match comes from someone of the same ethnicity - but only 2% of donors in 2021/22 were black, while black people are 4% of the population. Black families are also less likely to agree to organ donation than white families, the figures show. The NHS says there's an "urgent need" for more people from ethnic minorities to donate. Winnie Andango from NHS Blood and Transplant said, "Black people wait longer because there's less people coming forward to give their organs from their ethnic group. During covid, so many patients were suspended but those have been added back onto the list, and that means if we had less organs for this ethnic minority group, we have even less right now." Health Minister Neil O'Brien said: "We need more people, especially those from black and Asian heritage, to register their organ donation decision and share it with their family so loved ones can follow their wishes." Read full story Source: BBC News, 12 January 2023
  6. News Article
    An investigation by The Independent has revealed that the number of patients waiting more than 12 hours in A&E for treatment has exceeded 50,000 a week for the first time. Leaked NHS data shows that last month as many as one in eight patients faced a “trolley wait”—the time between attending A&E and being admitted—longer than 12 hours, as the health service comes under ever greater strain. Sources across the country told The Independent that hospitals are having to “squeeze” patients into spaces other than normal wards or A&E, with no direct oxygen lines. Meanwhile patients wait for hours in ambulances outside emergency departments. Read full story Source: The Independent, 11 January 2023
  7. Content Article
    In this article, Richard Murray, Chief Executive of The King's Fund, reflects on what 2023 has in store for the health and care system in England. Acknowledging the intense pressure all services are currently under, he highlights that patients aren't currently receiving the care they need meaning that coping with operational challenges is going to dominate the early part of the year for the health and care sector. He warns of the futility of the Government adding new performance management measures to the sector, and expresses hope that Integrated Care Boards (ICBs) could make a difference by bringing together stakeholders to tackle longer-term problems such as integration, population health and inequalities.
  8. Content Article
    In this article for NHS Confederation, Sir Chris Ham reflects on progress made against his recommendations on the conditions ICSs need to succeed and on next steps for the Hewitt review. He argues that progress has been made in acting on some of the recommendations in the report Governing the Health and Care System in England. This can be seen in plans to create a new NHS England (NHSE), reduce staffing at the centre and regions and co-produce the operating framework. However, he highlights that more work is needed to reduce the number of national NHSE programmes, ensure greater consistency in how these programmes work and bring an end to constant bidding for funds tied to specific priorities. He recommends that high priority be given to an organisational development (OD) programme to support the development of collaboration, mutual respect and trust and determine how peer support, shared learning and improvement collaboratives can play a bigger part in improving performance in future. Sir Chris highlights that the Hewitt review offers an opportunity for these and other issues to be addressed with priority being given to ensuring that planning guidance for 2023/24 is short and focused on a small number of national priorities, leaving scope for ICSs to add local priorities. Leaders in the DHSC and NHSE must recognise the exceptional pressures facing the health and care system and set out what a realistic set of medium-term objectives for ICSs looks like under current circumstances.
  9. Content Article
    Digital transformation across adult social care is occurring rapidly, however, uptake is not uniform, and the care sector is yet to fully harness digital tools to transform care delivery. With unprecedented service pressure and demand across health and care services, using digital tools in care settings has the potential to relieve some pressure by increasing efficiency and better supporting the workforce. This report by the think tank Public Policy Projects brings together the thoughts and ideas of many Adult Social Care experts regarding the future of the care sector, and the opportunities which digital advancements can bring. Chaired by Damian Green MP, it is intended as a thought-piece to guide action and further work on the area, as a guideline for future development.
  10. News Article
    The UK's health system is buckling under the weight of staff shortages and a lack of beds. In France, meanwhile, there are more doctors and many more nurses, yet its healthcare system is still in crisis. President Emmanuel Macron has promised to change the way its hospitals are funded, and to free doctors from time-consuming administration, in a bid to break what he called a "sense of endless crisis" in its health service. A series of eye-catching measures over the past few years - such as signing-up bonuses of €50,000 (£44,000) for GPs in under-served areas, and ending a cap on the number of medical students in France - have failed to plug healthcare gaps. Some hospitals are reporting up to 90% of their staff on "sick leave protest" at the conditions. And France's second-largest health union has called an "unlimited walkout" this week, following a fortnight of strikes by French GPs. Guillaume Garot, a Socialist MP leading a cross-party bill to tackle the problem of medical deserts, said, "Eight million French people live in a medical desert, and six million don't have an attending doctor," he says. "It takes six months, on average, to find an appointment in my department of Mayenne; in Paris it takes two hours." Read full story Source: BBC News, 12 January 2023
  11. Content Article
    Globally, the under-five mortality rate (U5MR) fell to 38 deaths per 1,000 live births in 2021, while under-five deaths dropped to 5.0 million. Although this demonstrates a decrease, this immense, intolerable and mostly preventable loss of life was carried unequally around the world , and children continue to face widely differing chances of survival based on where they are born. In contrast to the global rate, children born in sub-Saharan Africa are subject to the highest risk of childhood death in the world with a 2021 U5MR of 74 deaths per 1,000 live births – 15 times higher than the risk for children in Europe and Northern America and 19 times higher than in the region of Australia and New Zealand This report outlines and analyses figures from The United Nations Inter-Agency Group for Child Mortality Estimation (UN IGME) to examine levels and trends in child mortality around the world during 2022.
  12. News Article
    Five million children worldwide died before their fifth birthday in 2021, with almost half (47%) dying during their first month, according to new UN figures. Most of the deaths could have been prevented with better healthcare, say campaigners, adding that deaths among newborn babies haven’t reduced significantly since 2017. Children born in sub-Saharan Africa are 15 times more likely to die in childhood than children in Europe and North America. UN figures also show that 1.9 million babies were stillborn during 2021, more than three-quarters (77%) in sub-Saharan Africa and in south Asia. The risk of a woman having a stillborn baby in sub-Saharan Africa is seven times greater than for women in Europe and North America. Read full story Source: The Guardian, 10 January 2022
  13. News Article
    Novel strains of the coronavirus are creating new health concerns around the world as fresh descendants of the highly-transmissible Omicron variant now make up 40 per cent of cases in the US. The two strains, XBB and XBB.1.5 have seen a surge in cases in countries worldwide. The World Health Organisation has warned the new and “recombinant” Covid variant XBB.1.5 is the “most transmissible yet.” It has been nicknamed 'Kraken' on social media. XBB.1.5 has now been found in 25 countries and is a mutated version of Omicron XBB, which was first found in India in August. XBB can get past the body’s immune system and XBB.1.5 is just as able at doing so. It is also better at “binding” to cells, so it can spread with much more ease. Whether or not the so-called Kraken will trigger a new Covid surge in the UK remains to be seen, but reports suggests that a rise in cases may well be seen. Read full story Source: Independent, 11 January 2023
  14. News Article
    A record number of people in England are waiting longer than ever for cancer treatment, as the total waiting more than three months surpassed 12,000 for the first time. More than 4% of the 287,000 people on cancer waiting lists had waited more than 104 days to receive treatment after diagnosis, despite 2,000 of those being considered urgent patients, according to NHS England figures for the week ending on 1 January, seen by Health Service Journal. Michelle Mitchell, Cancer Research UK’s chief executive, said that missing waiting time targets–which have not been fully met since December 2015–was “unacceptable when a matter of weeks can be enough for some cancers to progress”. She called on the government to publish an “ambitious and fully funded” 10-year cancer plan. “Only then will we see significant improvements in early diagnosis and survival,” she said. Read full story Source: The Guardian
  15. Content Article
    This paper in the journal RSC Advances aimed to track changes in chemical bonding taking place in PP meshes on the nanoscale via mechano–chemical processes. The authors used the novel and advanced spectroscopic characterisation technique secondary electron hyperspectral imaging (SEHI) to build high resolution chemical maps. Polypropylene (PP) surgical mesh is associated with serious clinical complications when used in the pelvic floor for repair of stress urinary incontinence or support of pelvic organ prolapse. While manufacturers claim that the material is inert and non-degradable, there is a growing body of evidence that asserts PP fibres are subject to oxidative damage. Material surgically removed from patients suffering with clinical complications has shown some evidence of fibre cracking and oxidation. It has been proposed that a pathological cellular response to the surgical mesh contributes to medical complications, but the mechanisms that trigger the specific host response against the material are not well understood.  The study presented key insights into the mechano–chemistry reaction of PP which can cause polymer oxidation, changes in molecular structure, crack/craze formation and the release of etched oxidised insoluble particles. SEHI, provided a new route to link the effect of localised stresses to reactions of mechano–chemistry within PP. The method of mechanical distension testing during hydrogen peroxide exposure followed SEHI image analysis could form the basis of an “early warning” system which has the ability to identify materials which are not appropriate for use as medical implants.
  16. News Article
    A “most accomplished fraudster” was paid between £1m and £1.3m by the NHS during the nearly two decades she posed as a qualified doctor after forging a degree certificate, a court has heard. Zholia Alemi, believed to be 60 years old, worked as a psychiatrist in the UK for 19 years after claiming to have qualified at the University of Auckland in New Zealand, a trial at Manchester crown court heard. The defendant is accused of 20 offences, including forgery and fraud, which she denies. The jury heard Alemi’s case was that she was appropriately qualified and documents demonstrating her qualifications were genuine. She denies 13 counts of fraud, three counts of obtaining a pecuniary advantage by deception, two counts of forgery and two counts of using a false instrument. Read full story Source: The Guardian (paywalled)
  17. News Article
    Patients have suffered cardiac and respiratory arrests because of errors using oxygen cylinders, NHS England has warned, citing more people being cared for in “areas without access to medical gas pipeline systems” such as corridors and ambulances queuing outside A&E. A patient safety alert issued by NHS England today identifies 120 incidents in the past year related to oxygen cylinder use, including cylinders either being empty at point of use, not switched on, inappropriately transported, or inappropriately secured. Some of the incidents involved “compromised oxygen delivery to the patient, leading to serious deterioration and cardiac or respiratory arrest” the alert said, and at least 43 caused harm. Read full story (paywalled) Source: HSJ, 10 January 2023
  18. Content Article
    This blog for Refinery 29 by journalist Sarah Graham examines the gender health gap, a term used to describe the inequalities in treatment and health outcomes that men and women experience. She talks about the stories relating to sexism and institutional bias she has come across during her time as a health journalist, that result in poor care experiences and outcomes for women. While acknowledging that women should not have to make extra effort to be heard by the health system, Sarah offers tips for women to help them voice their concerns and improve their chances of being listened to by medical professionals.
  19. Content Article
    Appreciative Inquiry (AI) is a transformational change methodology grounded in theories from the disciplines of human sciences and philosophy. It invites people to see themselves and the world through an appreciative or valuing eye. This article by AI strategist Robyn Stratton-Berkessel aims to provide an overview of AI for beginners, and covers: What is Appreciative Inquiry How it is a strengths-based, positive framework What it can achieve through collaborative conversations The 4-D process of Appreciative Inquiry – known as the Appreciative Inquiry Model How it can be applied personally and professionally The guiding principles (Including the new addition of the five emerging principles) The importance of Appreciative Inquiry questions – affirmatively-framed questions The value of story-telling in Appreciative Inquiry
  20. Content Article
    Even before the Covid-19 pandemic, rural and remote health services in England faced long-standing workforce, financial and capacity issues. This report by the Nuffield Trust explores the impact the pandemic has had on the delivery of rural and remote health services, highlighting the underlying challenges faced by these services. It outlines how the challenges faced are different for rural areas when compared to more urban areas. The authors also discuss how performance could be monitored to signal the risk of any significant service pressures over the coming months.
  21. Content Article
    In this article for The Guardian, an anonymous hospital consultant describes the situation in many NHS emergency departments in January 2023—patients ready for medical admission waiting in ambulances in the hospital car park, patients receiving IV antibiotics in chairs in the corridor and staff completely overwhelmed by the workload. The author highlights that accident and emergency departments are now being used for a purpose for which they were not designed—looking after patients who need to be admitted to hospital wards. They describe the implications of this on patient safety and staff wellbeing and argue that the NHS and Government need to call the situation what it is—a crisis—or we will come to accept poor quality care and low patient safety standards as the norm.
  22. News Article
    More than 650,000 deaths were registered in the UK in 2022 - 9% more than 2019. This represents one of the largest excess death levels outside the pandemic in 50 years. Though far below peak pandemic levels, it has prompted questions about why more people are still dying than normal. Data indicates pandemic effects on health and NHS pressures are among the leading explanations. Although the ongoing impact of the pandemic is a contributing factor, a number of doctors are blaming the wider crisis in the NHS. On 1 January 2023, the president of the Royal College of Emergency Medicine suggested the crisis in urgent care could be causing "300-500 deaths a week". Read full story Source: BBC News, 10 January 2023
  23. News Article
    More than 7,000 nurses at two major New York City hospitals walked off the job Monday, arguing immense staffing shortages are causing widespread burnout and hindering their ability to properly care for their patients. The nurses say they are working long hours in unsafe conditions without enough pay – a refrain echoed by several other nurses strikes across the country over the past year. The union representing the nurses said an offer of 19% pay hikes isn’t enough to solve staffing shortages. This is the latest in a series of strikes in the health care industry in recent years. Those union members who were on the front lines during the three-year battle with the Covid pandemic say the system is no longer able to function with the widespread shortages that arose during those years. “We’ve been fighting for working under safer conditions,” Warren Urquhart, a transplant nurse at Mount Sinai, told CNN Monday while on the picket line. “We do the best we can every day. There’s something wrong inside the hospital. That’s why we’re outside the hospital.” Read full story Source: CNN, 9 January 2023
  24. Content Article
    This document outlines NHS England's approach to learning from safety culture best practice. It covers: Safety culture context within the NHS patient safety strategy Leadership Continuous learning and improvement Measurement and systems Teamwork and communication Psychological safety Inclusion, diversity and narrowing healthcare inequalities Case studies
  25. News Article
    Ambulance staff will take part in their second day of strike action this winter on Wednesday 11 January. Alongside paramedics, call-centre staff will walk out across England and Wales in the dispute over pay. These workers play a vital role, taking calls from the public and assigning ambulance crews. An ambulance dispatcher at the North West Ambulance Service, who wishes to stay anonymous, has described working amid the extreme pressures of this winter. They said, "The thought of going in and having to manage those calls just fills me with absolute dread. I have seen people leave the ambulance service - they have had enough. We are physically and mentally exhausted." Most frustrating, the dispatcher says, is the number of crews stuck outside hospital waiting to hand patients over to accident-and-emergency staff. In the last week of 2022, more than 40% of crews in England had waits of more than 30 minutes - it should take 15. Read full story Source: BBC News, 10 January 2023
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