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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This guide by the Royal College of Physicians explains what a hip fracture is and answers questions about how patients will be cared for before and after a hip operation. It is written for patients and their families and carers. The guide covers aspects of hip fracture care such as: pain relief memory problems who should be involved in your care how soon an operation should take place eating and drinking bladder problems rehabilitation and physiotherapy following surgery when you will be able to go home future falls prevention bone strengthening medication
  2. Content Article
    This letter accompanies the publication of the Patient Safety Incident Response Framework (PSIRF) by NHS England. The PSIRF forms a major part of the NHS Patient Safety Strategy and replaces the Serious Incident Framework (SIF) that has been in place since 2015. It aims to improve safety management across the healthcare system in England and to support the NHS to embed the key principles of a patient safety culture. In his letter, Dr Aiden Fowler, National Director of Patient Safety in England outlines how PSIRF was developed, describes how the transition from the SIF to PSIRF will take place and highlights the tools available to support organisations to implement the changes. The letter is addressed to: NHS trust and foundation trust chief executives, medical directors and nursing directors Integrated Care Board medical directors and nursing directors NHS England Regional Team medical directors and nursing directors NHS England regional direct commissioning leads
  3. Content Article
    Non-ventilator-associated hospital-acquired pneumonia (NVHAP) is one of the most common and deadly healthcare-associated infections, but it is not tracked, reported or actively prevented by most hospitals. This article in the journal Infection Control & Hospital Epidemiology highlights a national call to action to address NVHAP in the US. This national call to action includes: launching a national healthcare conversation about NVHAP prevention. adding NVHAP prevention measures to education for patients, healthcare professionals, and students. challenging healthcare systems and insurers to implement and support NVHAP prevention. encouraging researchers to develop new strategies for NVHAP surveillance and prevention.
  4. Content Article
    This article and video tell the story of Rihan Neupane, a baby born prematurely in Dhapasi, Nepal, who was left in a vegetative state following a series of medical errors including a missed diagnosis of meningitis. His parents had chosen a private international hospital for their maternity care, but were let down by a series of medical errors including Rihan being mistakenly given a massive paracetamol overdose. Although external hospital safety inspectors found the hospital negligent on many counts, the hospital continued to deny any wrongdoing or responsibility for Rihan's condition. Rihan's father Sanjeev Neupane talks about his family's experience in the embedded video.
  5. Content Article
    When hospital patients do not have their teeth brushed it can lead to them developing pneumonia—poor dental hygiene in hospital is believed to be a leading cause of hundreds of thousands of cases of pneumonia a year. In this blog for Medscape, reporter Brett Kelman looks at the link between dental hygiene and hospital-acquired pneumonia, which kills up to 30% of patients who are infected with it. He highlights a lack of understanding of the impact of failing to brush inpatients' teeth, in spite of a growing body of research evidence that links lack of adequate toothbrushing to pneumonia infection.
  6. Content Article
    This blog provides an overview of a discussion at a Patient Safety Management Network (PSMN) meeting on 26 August 2022. The discussion considered the use of two different system-based approaches for learning from patient safety incidents recommended by the NHS Patient Safety Incident Response Framework (PSIRF). The PSMN is an informal voluntary network for patient safety managers. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance, offer peer support and create a safe space for discussion. You can find out more about the network here
  7. News Article
    There are big differences in how well patients with hip fractures are cared for by hospitals in England and Wales, a Bristol University study says. In some hospitals one in 10 people died within a month of surgery - more than three times worse than in the best. Getting patients into theatre quickly and out of bed the next day for physio are key ways to improve care. People should receive the same, high-quality care wherever they live, the researchers said. "If you get it right for older people with hip fractures, you're probably getting it right for older people in general," says Professor Celia Gregson, who led the study of more than 170,700 patients in 172 hospitals between 2016 and 2019. An NHS spokesperson said hip fracture care in the UK had "seen dramatic improvements in recent years". Read full story Source: BBC News (31 August 2022)
  8. Event
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    The Covid-19 pandemic has led to a dramatic increase in the percentage of adults showing moderate or severe symptoms of depression. The Office for National Statistics said that over 16% of adults were affected in 2020 – compared with around 10% in 2019. Those affected were more likely to feel stressed or anxious and worried about their future than in 2019. Many of these people will need support and treatment from the NHS – and may not have sought it during the pandemic. In addition, financial pressures over the coming years may lead to more cases of depression. Some will seek help from their GP and be referred onwards for treatment – often to the sort of “talking therapies” used in IAPTs. But getting access to these is not always straightforward or quick, and patients can often represent to their GP seeking help. In addition, patients can suffer low points but not be able to access support until their next IAPTs session. This HSJ webinar, in association with Ethypharm Digital Therapy, will look at these issues and ask what solutions are available. What is the current situation with support for those with depression and how does it impact on GPs and other primary care professionals, as well as patients? What are the challenges around existing IAPTs capacity? Is there scope for other existing mental health services to assist? How can digital solutions be used to increase capacity? How can solutions be scaled up for use across an integrated care system area? Speakers include: Dr Kate Lovett, consultant psychiatrist, former dean of the Royal College of Psychiatrists Andy Bell, deputy chief executive, Centre for Mental Health Hélène Moore, Pharmaceutical, Ethypharm Claire Read, HSJ contributor (webinar chair) Register for the webinar
  9. Content Article
    Babylon is a US company that offers AI-powered online apps to health systems. Several UK hospital trusts have used Babylon apps to triage patients and reduce attendances at accident and emergency departments since 2018. In this blog, Nicole Kobie, contributing editor at technology website Wired, looks at Babylon's recent cancellation of its last contract with an NHS trust. She highlights that although some welcome Babylon's exit from the NHS, the disruption caused by the apps' implementation was costly and has left some trusts with large bills. The apps also triggered complaints from the Medicines and Healthcare products Regulatory Agency (MHRA) after concerns that Babylon's AI was missing signs of serious illness. The article highlights the need to carefully consider patient safety and cost-effectiveness when introducing new technologies into health systems, and take a slower approach to rolling out AI innovations.
  10. Event
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    Medication-related harm accounts for up to half of the overall preventable harm in medical care. Patients in low- and middle-income countries are twice more likely to experience preventable medication harm than patients in high-income countries. Considering this huge burden of harm, “Medication Safety” has been selected as the theme for World Patient Safety Day 2022. To commemorate the day, WHO is organizing a Global Virtual Event, calling on all stakeholders to join efforts globally for “Medication Without Harm”. During the event, stakeholders will discuss medication safety issues within the strategic framework of the WHO Global Patient Safety Challenge: Medication Without Harm, including 1) Patients and the public, 2) Health and care workers, 3) Medicines, and 4) Systems and practices of medication. Interpretations will be available in Arabic, Chinese, English, French, Hindi, Portuguese, Russian and Spanish. Register for the webinar Save the date-flyer_Global Virtual Event WPSD 2022_15 September 2022.pdf
  11. Content Article
    This report revisits the conclusions of The Health Foundation's Covid-19 impact enquiry, which found that poor health and existing inequalities had left parts of the UK more vulnerable to the virus and had influenced its devastating impact. A year on from the impact inquiry, more than 90% of the UK population have had at least one Covid-19 infection, and 74% of adults had received three vaccinations by April 2022. This report considers: the further direct impact of Covid-19 on health outcomes. the broader implications for social determinants of health. the extent to which previously highlighted risks to health have been addressed. the implications for the country of ‘living with Covid-19’.
  12. Content Article
    This report by the Institute for Fiscal Studies (IFS) looks at which staff are more likely to leave the NHS acute sector. There is still little analysis available on the reasons why staff leave the NHS, but increasing our understanding of the complex factors that cause people to leave the health service would allow the NHS to develop more effective retention strategies. The report uses the Electronic Staff Record, the monthly payroll of directly employed NHS staff, to analyse the leaving rates of consultants, nurses and midwives, and health-care assistants (HCAs) between 2012 and 2021. The authors highlight that many other factors that influence retention remain unknown, and much more research is needed in this area.
  13. News Article
    The finalists for The Innovate Awards 2022 have been revealed following a rigorous round of judging over the summer, and Patient Safety Learning is a finalist in the 'Enabling Safer Systems of Care Through Innovation' category. In its inaugural year, The Innovate Awards saw a grand total of 194 entries from health and care teams across the country covering ten award categories. The ten eventual winners will also compete for ‘Innovation Champion of the Year’ to be announced on the evening of the award ceremony in September. Commenting on the awards, Matthew Taylor, Chief Executive, NHS Confederation from NHS Confederation said: “Judges across all the award categories have remarked on how impressive and inspiring the work contained in these submissions has been. It has been a delight to see the wonderful efforts taking place in terms of innovation in the health and care sector and it is hugely important to recognise and celebrate this.” Read full story Source: AHSN Network (30 August 2022)
  14. Content Article
    This paper in the journal Social Science & Medicine reports from an ethnographic study of hospital planning in England between 2006 and 2009. The authors explored how a policy to centralise hospital services was promoted in national policy documents, how this shifted over time and how it was translated in practice. They found that policy texts defined hospital planning as a clinical issue and framed decisions to close hospitals or hospital departments as based on the evidence and necessary to ensure safety. They argue that this clinical rationale is sometimes a false reframing of a political motivation, that it constrains public participation in decisions about the delivery and organisation of healthcare, and that it restricts the extent to which alternatives can be considered.
  15. News Article
    Patients will be able to use the NHS app to shop around for hospitals with the shortest waiting lists in a renewed drive to cut backlogs for routine care. Health bosses agreed yesterday to give patients more choice over where they are treated by next April in an effort to use digital league tables to direct people towards hospitals with the shortest waits. Steve Barclay, the health secretary, wants to give patients “real-time data” on their phones to decide whether to travel further to get quicker treatment for hip replacements, cataract removals and other non-urgent procedures. A government source said: “We don’t need a big bureaucracy to funnel patients towards the hospital which NHS managers decide is best, when, armed with a right to choose and the right information on the app, patients will go where waiting times are lowest.” Read full story (paywalled) Source: The Times (31 August 2022)
  16. Content Article
    This blog by Professor Michael Marmot, Professor of Epidemiology, University College London looks at the ways in which the Covid-19 pandemic both exposed and amplified underlying inequalities in society. He highlights the link between higher Covid mortality rates, race and deprivation that demonstrates the striking health inequalities that exist in the UK. He asks the question, "Can the UK learn the lessons of the pandemic, and build back fairer?"
  17. Content Article
    Processes relating to communication between healthcare professionals are complex and vulnerable to breakdown. In the electronic health record (EHR)-enabled healthcare environment, providers rely on technology to support and manage complex communication processes, and if implemented and used correctly, EHRs have potential to improve safety. This clinician communication self-assessment guide aims to help healthcare professionals determine how safe their practice is in relation to electronic health records (EHR) and communication.
  18. News Article
    Nearly 1.5 million patients have lost their GP in the last eight years after the closure of almost 500 practices, research has suggested. Issues around recruitment were a factor in the closure of about two-fifths of the surgeries, while workloads and inadequate premises were also cited as triggers. The investigation, by Pulse magazine, revealed for the first time the number of premises that have closed for good since 2013. Previously, research has identified the number of practices where GP partners have returned their contracts, or certain branches have closed or merged with others. Prof Martin Marshall, the chairman of the Royal College of GPs, said: “The impact of a practice closing on its patients and neighbouring practices can be considerable. As such, a decision to close a practice will be one of the most difficult a GP partner can make. When the reason for closing a practice is workload pressures, and not being able to fill vacancies, then this needs to be addressed as a matter of urgency.” Read full story (paywalled) Source: The Telegraph (29 August 2022)
  19. Content Article
    This study in the Journal of the American Medical Informatics Association aimed to evaluate the feasibility of using Unified Medical Language System (UMLS) semantic features for automated identification of reports about patient safety incidents by type and severity. UMLS was compared with results produced by bag-of-words (BOW) classifiers on three testing datasets. The authors found that UMLS-based semantic classifiers were more effective in identifying incidents by type and extreme-risk events than classifiers using bag-of-words (BOW) features.
  20. News Article
    Major concerns are being raised about the Irish State’s failure to set up an inquiry into a drug that caused serious birth defects and developmental delays in at least 1,200 Irish babies. Sodium valproate, a drug used to treat epilepsy and bipolar disorder, has been estimated to have caused major malformations in up to 341 Irish children between 1975 and 2015 after it was taken by their mothers during pregnancy. The drug, which is sold in Ireland as Epilim, is also believed to have caused neuro-developmental delays in 1,250 children. Many women were never warned of the risks that taking the drug during pregnancy would pose to their babies. Read full story Source: The Irish Independent
  21. News Article
    The average life expectancy of Americans fell precipitously in 2020 and 2021, the sharpest two-year decline in nearly 100 years and a stark reminder of the toll exacted on the nation by the continuing coronavirus pandemic. In 2021, the average American could expect to live until the age of 76, federal health researchers reported on Wednesday. The figure represents a loss of almost three years since 2019, when Americans could expect to live, on average, nearly 79 years. The reduction has been particularly steep among Native Americans and Alaska Natives, the National Center for Health Statistics (NCHS) reported. Average life expectancy in those groups was shortened by four years in 2020 alone. “Even small declines in life expectancy of a tenth or two-tenths of a year mean that on a population level, a lot more people are dying prematurely than they really should be,” said Robert Anderson, chief of mortality statistics at the NCHS. Read full story (paywalled) Source: The New York Times (31 August 2022)
  22. News Article
    More than ten million patients are on “hidden” waiting lists for NHS care. There are 6.7 million patients on the official NHS waiting list, which includes people who have been referred by GPs for hospital treatment such as cataract or hip and knee surgery. However, data released by health service trusts under freedom of information laws suggests there are 10.3 million further patients who need follow-up care, illustrating the scale of the task facing the NHS. Louise Ansari, national director at the patient group Healthwatch England, said: “Waiting a long time for treatment can put a huge strain on patients and their loved ones. But this can be so much worse when there is ‘radio silence’ from the NHS, leaving people uncertain if their referral has been accepted, unclear about how long they may have to wait and often feeling forgotten.” Read full story (paywalled) Source: The Times (30 August 2022)
  23. News Article
    Patients waiting for surgery are turning up at A&E because they “can't cope”, the head of the NHS Confederation has warned. Matthew Taylor, chief executive of the body which represents all areas of the health service, said the NHS was in a "terrible situation" where it was facing "more demand than we can deal with". Some 6.7 million people are waiting to start hospital treatment after being referred by their GP, latest official data show. Urgent and emergency care is also under significant pressure, with 12-hour A&E waits increasing by a third in July to reach 29,317 - the worst on record. "We also know that people, many people, who are sick in the community waiting for operations, for example, and that's one of the reasons people end up in the emergency department because they get to the stage where they can't cope,” Mr Taylor said. "So the problem is that pressures in one part of the system drive pressure in others.” Read full story (paywalled) Source: The Telegraph (30 August 2022)
  24. News Article
    A proposed pay settlement is making doctors consider leaving the health service, the British Medical Association (BMA) in Northern Ireland has said. In a BMA survey of more than 1,000 doctors, 85% of respondents said the proposed uplift of 4.5% was too low. The representative body said discontent was very high among junior doctors with 93% of them saying it was too low. "When asked about their intentions as to the likelihood of them continuing to work in Northern Ireland, junior doctors said they were now more likely to leave because of the low pay award," said the BMA. Read full story Source: BBC News (31 August 2022)
  25. News Article
    Flu could “bite” months earlier than usual this year, NHS leaders and scientists have warned, leading to calls for millions to get their vaccination against the disease as soon as possible. Around 20 million people in the UK, including all over-50s, will be offered a free jab this winter, as ministers fear the combination of a bad flu season, Covid and a cost of living crisis could lead to a spike in deaths. Saffron Cordery, the interim chief executive of NHS Providers, which represents trusts in England, warned that this year flu had “come early and severely to parts of the southern hemisphere, and we’re going see it here potentially biting in October”. Read full story Source: The Independent (30 August 2022)
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