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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. News Article
    At the beginning of this year, there was a thrum of excitement among global health experts: Eradication of polio, a centuries-old foe that has paralyzed legions of children around the globe, seemed tantalizingly close. But there were several ominous setbacks. Malawi in February announced its first case in 30 years, a 3-year-old girl who became paralyzed following infection with a virus that appeared to be from Pakistan. Pakistan itself went on to report 14 cases, eight of them in a single month this spring. In March, Israel reported its first case since 1988. Then, in June, British authorities declared an “incident of national concern” when they discovered the virus in sewage. By the time New York City detected the virus in wastewater last week, polio eradication seemed as elusive as ever. “It’s a poignant and stark reminder that polio-free countries are not really polio-risk free,” said Dr. Ananda Bandyopadhyay, deputy director for polio at the Bill & Melinda Gates Foundation, the largest supporter of polio eradication efforts. The virus is always “a plane ride away,” he added. Read full story (paywalled) Source: The New York Times (18 August 2022)
  2. Content Article
    A Treatment Escalation Plan (TEP) is a communication tool designed to improve quality of care in hospital, particularly if patients deteriorate. TEPs aim to reduce variation caused by discontinuity of care, avoid harms caused by inappropriate treatment and promote patients’ priorities and preferences. This article in the Journal of the Royal College of Physicians of Edinburgh examines the key components of a TEP, how and why TEPs should be implemented and the outcome-related evidence to support their use.
  3. News Article
    Hospital bosses have warned that they face “impossible choices” under Liz Truss’s plan to divert £10 billion a year from the NHS to social care. They say that her pledge to remove cash earmarked for the health service will “slam the brakes” on efforts to tackle record waiting lists, with patients bearing the brunt. An extra £36 billion has been ring-fenced for health and care spending over the next three years, of which less than £2 billion a year is due to go towards social care. Truss, the frontrunner in the Conservative leadership contest, has announced that as prime minister she will divert the entire amount to local authorities to pay for older people’s care. This would create a £10 billion shortfall in annual NHS spending, the equivalent of imposing a 7 per cent budget cut on the service. NHS bosses say that they would have no choice but to cut services as they face the worst winter crisis in living memory, forcing patients to wait longer for treatment. There are already 6.7 million people on waiting lists, while patients are dying because of a sharp increase in ambulance response times and accident and emergency waiting times are the worst on record. Truss told a Times Radio hustings: “I still would spend the money. I would just take it out of general taxation rather than raising national insurance. But I would spend that money in social care. Quite a lot has gone to the NHS. I would give it to local authorities.” Read full story (paywalled) Source: The Times (25 August 2022)
  4. News Article
    Nurses at 15 hospitals in the Twin Cities area (Minneapolis-St Paul) and Duluth, Minnesota, that are negotiating new union contracts with their respective hospitals have overwhelmingly voted to authorize a strike. A date for the work stoppage has not been set yet by the union, the Minnesota Nurses Association, which represents about 15,000 nurses who voted on the strike authorization, but a 10-day notice must be given ahead of any strike. If a strike is carried out, it would be one of the largest nurses’ strikes in US history. Jayme Wicklund, a registered nurse at the Children’s hospital in St Paul, Minnesota, and member of the negotiating committee, said, “We need more resources to take care of the patients. The hospitals are very focused on wages. We have to be comparable to other places. But that’s all that they focus on. Once you start talking about wages, they don’t want to talk about the other important issues around patient safety or actually, other ways to save money.” Read full story Source: The Guardian (23 August 2022)
  5. News Article
    Rishi Sunak has claimed that it was a mistake to “empower scientists” during the coronavirus pandemic and that his opposition to closing schools was met with silence during one meeting. The Conservative leadership candidate believes one of the major errors was allowing the Scientific Advisory Group for Emergencies (Sage) to have so much influence on decision making such as closing nurseries, schools and colleges in March 2020. Sunak also disclosed that he was banned from discussing the “trade-offs” of imposing coronavirus-related restrictions such as missed doctor’s appointments and NHS waiting list backlogs. In an interview with the Spectator to be published on Saturday, the former chancellor said: “We shouldn’t have empowered the scientists in the way we did. And you have to acknowledge trade-offs from the beginning. “If we’d done all of that, we could be in a very different place. We’d probably have made different decisions on things like schools.” Read full story Source: The Guardian (24 August 2022)
  6. News Article
    The NHS has been forced to publish hidden trolley waits data, after intervention by the UK Statistics Authority, The Independent has learned. In a letter to NHS Digital and NHS England in July, Ed Humpherson director general for regulation at UKSA asked the organisations to publish monthly data on patients whose total wait in A&E is longer than 12 hours, following an ongoing row with emergency care leaders. NHS England promised to publish this internal data but has yet to comply, and as a result it was referred to UKSA by the Royal College of Emergency Medicine over concerns that the public data is misleading. Dr Katherine Henderson, president of the Royal College of Emergency Medicine, told The Independent: “For some time, we have been calling for NHS England to publish the 12-hour data measured from time of arrival. This data will show the real scale and depth of the crisis that urgent and emergency care is facing. We believe that through transparency around the sheer number of patients facing 12-hour waits, we can drive political and health leaders into action. Read full story Source: The Independent (25 August 2022)
  7. News Article
    Firefighters have resorted to taking people to hospital in fire engines amid rocketing call-outs to medical emergencies. Fire and rescue services now respond to more “non-fire incidents” than fires in England, including cardiac arrests, suicide attempts and elderly people trapped in their homes after falls. Official statistics show that they attended more than 18,200 medical incidents in 2021-22, an increase of a third from the previous year, and that firefighters rather than ambulances were the “first responder” in almost half of those calls. Chris Lowther, who chairs the National Fire Chiefs’ Council’s operations committee, said the figures showed a “new reality” as firefighters step in to help struggling ambulance services. Read full story Source: The Independent (22 August 2022)
  8. News Article
    The mother of a seven-year-old girl who died at Perth Children's Hospital says she pleaded with staff to help her daughter but was not taken seriously. Aishwarya Aswath died in April last year after attending the Perth Children's Hospital (PCH) with a high temperature and cold hands. The Perth Coroner's Court on Wednesday heard a statement from Aishwarya's mother Prasitha Sasidharan, who described how she grew increasingly worried about her daughter while in the hospital waiting room. She approached staff five times while they were in the waiting room for almost two hours. "I feel like I was ignored and not taken seriously," she said. The court heard from both parents on Wednesday, the start of an eight-day inquest. After Aishwarya died her father wanted to hold her but was only allowed to do so for a brief time. In his statement, read to the court, he said there were "many missed opportunities to save her." Former PCH chief executive Aresh Anwar said the hospital was grappling with a rise in mental health presentations and a shortage of staff when Aishwarya died. Read full story Source: ABC News (24 August 2022)
  9. News Article
    Kath Sansom, a former journalist from Lynn is raising awareness about the potential risks associated with vaginal and rectal mesh surgery. Mesh implant surgery is used to treat prolapse and incontinence in women usually following childbirth, and some men have also had the procedure. But pain and complications after the implants have left hundreds of people in the UK in pain and so a campaign in 2015 was launched which has led to the Government announcing a suspension in the use of vaginal mesh. Kath initiated the Sling The Mesh campaign in 2015 following her own experience of mesh surgery. She said: "What is most important to women is financial redress. We are all innocent and have had our health and lives compromised. We shouldn't have to wait 40 years, as the victims of contaminated blood have. Some women are in wheelchairs and have lost pensions. I am not the woman that I was. It has taken a financial, physical and emotional toll." Read full story Source: Lynn News (24 August 2022)
  10. Content Article
    In this joint blog, Patient Safety Learning and Sling the Mesh highlight several issues with the specialist mesh centres set up by the NHS to provide treatment and surgery for women who have been harmed by mesh. We identify key patient safety issues and look at what needs to be done to ensure women receive timely, compassionate and appropriate treatment for complications they face as a result of mesh implants.
  11. News Article
    An acute trust has “palpable” cultural problems and staff “at all levels” have described an acceptance of “poor behaviours”, according to the Care Quality Commission. Some staff at Gloucestershire Hospitals Foundation Trust also reported a lack of trust in their senior managers and a “fear of speaking up”. The Care Quality Commission feedback was set out in a post-inspection letter to the trust’s acting chief executive Mark Pietroni last month following an inspection in June. The trust’s CEO Deborah Lee is currently off work as she recovers from a stroke. According to the CQC letter, published in the trust’s board papers ahead of a full inspection report which is due in the autumn, staff “articulated [to inspectors and said they] had observed rudeness and incivility throughout the organisation”. In a written statement, Professor Pietroni told HSJ he “fully recognised” the CQC’s feedback. Read full story (paywalled) Source: HSJ (24 August 2022)
  12. Content Article
    Compensation claims are a useful source of information on patient safety research. This study in The Journal of Patient Safety aimed to determine the main causes of surgical compensation claims and their financial impact on the health system. The authors analysed the frequency, causes, consequences, locations and surgical settings of compensation claims brought against the surgical area of the Murcia Health System between 2002 and 2018. The study found that the most frequent causes for claims were surgical error (42.4%) and treatment error (30.9%), and that the main surgical settings involved were orthopaedic surgery and traumatology (27.4%), gynaecology and obstetrics (25.7%) and “general surgery” (17.2%).
  13. Content Article
    In this opinion piece in The BMJ, consultant radiologist Giles Maskell examines changes to the ways in which medical imaging is used in the health service. He states that imaging used to be ordered, when necessary, at the end of a diagnostic process, whereas now many doctors are asking for scans before they will see a patient for the first time. The article highlights some of the implications of this shift in practice, including on screening service capacity and on the interpretation of test results.
  14. Content Article
    This leaflet produced by the Irish Health Services Executive (HSE) provides a central place for patients to record information about their medications. It acts as a reference point for patients to use when discussing their medications with a healthcare professional and includes a reminder of the Know, Check, Ask campaign, aimed at reducing medication errors in the community.
  15. Event
    until
    After two years with virtual workshops due to the Covid-19 pandemic, we are pleased to announce that the fifth International Workshop on Safety-II in Practice will be organised on site in Edinburgh, Scotland on September 7-9, 2022. The Workshop is organised by FRAMsynt. The workshop will begin with an optional half-day tutorial on Safety-II in Practice in the afternoon of September 7 (1330-1730 BST), and continue with two days of meetings and discussions from September 8 (0830-1700 BST) to September 9 (0830-1500 BST). There will be a walking tour of Edinburgh old town (hosted by Steven Shorrock) and a dinner on the evening of September 8 for those who wish to join. Aim of the workshop The aim of the workshop is to share experiences from existing and/or planned applications of a Safety-II approach in various industries and practices. The workshop will give the participants an opportunity to present and discuss problems encountered and lessons learned – good as well as bad, practical as well as methodological. The workshop is a unique opportunity for safety professionals and researchers to interact with like-minded colleagues, to debate the strengths and weaknesses of a Safety-II approach, and to share ideas for further developments. The guiding principle for the workshop is “long discussions interrupted by short presentations”. In order to achieve this, the number of participants will be limited to 60 – first come, first served. Participation The workshop is open to everyone regardless of their level of experience with Safety-II. It will address the use of Safety-II in a variety of fields and for purposes ranging from investigations, performance analyses, organisational management and development, individual and organisational learning, and resilience. The workshop will provide a unique opportunity to: Discuss and exchange experiences on how a Safety-II approach can be used to analyse and manage complex socio-technical systems. Receive feedback on and support for your own Safety-II projects and ideas. Learn about the latest developments and application areas of Safety-II. Develop a perspective on the long-term potential of a Safety-II approach. Discussion topics, presentations and papers You can contribute actively to the workshop by submitting proposals for: Topics or themes for panel discussions (preferably with a presentation or introduction, but open suggestions of themes are also welcome). Presentations of ongoing or already completed work in industry and/or academia. Ideas that you would like to get a second opinion on. Questions or issues that you have been wondering about and would like to hear more about. The relevance of a Safety-II perspective for individual and organisational learning. The strategic management of Safety-II: how to introduce changes to routines and daily practice. For each type of proposal, please provide a short abstract (about 100 – 200 words, but even less if need be) with a summary of what you would like to present or discuss and how you want to be involved. All proposals will be reviewed and comments to the submitters will be provided. Please submit your proposed contribution to: contact@humanisticsystems.com Register
  16. News Article
    Up to 100 nurses are to be recruited from Nepal to work in the NHS, despite global restrictions on employing health workers because of staff shortages in the country. The Department of Health and Social Care (DHSC) and the Government of Nepal have signed a new government-to-government agreement regarding the recruitment of Nepali health professionals to the UK. The move comes after the new health and social care secretary Steve Barclay announced plans to “significantly increase” overseas recruitment of health workers to help mitigate staff shortages in the UK. A 15-month pilot phase will initially see up to 100 nurses recruited from Nepal to work at Hampshire Hospitals NHS Foundation Trust. Read full story Source: Nursing Times (23 August 2022)
  17. News Article
    Patients may come to harm as a result of NHS 111 chaos, experts claimed on Tuesday as patients were advised to avoid the service this weekend. The helpline for urgent medical advice was targeted by cyberhackers earlier this month, leaving staff working on pen and paper. The Adastra computer software, used by 85 per cent of 111 services, was taken offline after the attack leaving call handlers unable to book out-of-hours urgent appointments and fulfil emergency prescriptions. But almost three weeks on, most staff are still operating without the system, leaving GPs unable to see patients’ medical records during urgent consultations or automatically forward prescriptions to pharmacies. The NHS has told hospitals to prepare public awareness campaigns to “minimise” pressures on urgent and emergency care services this winter. Some hospitals have already issued messaging urging patients not to turn up at accident and emergency (A&E), unless they are facing a “serious emergency.” Helen Hughes, chief executive of the charity Patient Safety Learning, said the continuing chaos raises “serious patient safety concerns” and will “inevitably result in avoidable harm”. Telling patients not to go to A&E “unless it is absolutely necessary” is only possible if GPs and NHS 111 “have the capacity and the resources to meet the demands that this places on them”, Ms Hughes said. “Significant delays in receiving a response are potentially missed opportunities for patients to receive timely medical advice and treatment that may prevent future harm,” she added. “Delays in receiving timely care and treatment will inevitably result in avoidable harm to patients.” Read full story (paywalled) Source: The Telegraph (23 August 2022)
  18. Content Article
    In partnership with the Healthcare Safety Investigation Branch (HSIB) and Learn Together, NHS England has published its Guide to engaging and involving patients, families and staff following a patient safety incident alongside the Patient Safety Incident Response Framework (PSIRF). This guide sets out expectations for how those affected by an incident should be treated with compassion and involved in any investigation process. In this podcast, the speakers introduce the guide, discuss how it was developed, and talk about future plans in the area of work. Speakers: Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England National Patient Safety Team Lauren Mosley, Head of Patient Safety Implementation, NHS England National Patient Safety Team Lou Pye, Head of Family Engagement, HSIB Jane O’Hara, Learn Together research team, Professor of Healthcare Quality and Safety, University of Leeds and Deputy Director of the Yorkshire Quality and Safety Research Group.
  19. News Article
    Liz Truss has pledged to halt the exodus of doctors from the NHS to tackle the Covid backlog and surging waiting lists. The frontrunner in the Conservative leadership race is planning to unveil a series of radical reforms that will stop doctors from retiring early and entice retirees to return. One in 10 consultants and GPs is expected to retire in the next 18 months because of pension rules that mean they are "paying to work". A source close to her said she would deal with it by “cutting red tape and dealing with issues in the pension and tax system that currently act as barriers for people wanting to return”. It comes amid concerns that the NHS backlog after lockdown is causing more than 1,000 excess deaths per week - more than the figure now killed each week by coronavirus. A source close to Liz Truss also said: “The Covid pandemic put unprecedented strain on our NHS, and the resulting backlog is seeing people struggling to get appointments and treatments. We must act to tackle it, and we will. We will make it easier for doctors and nurses who have recently left or are planning to leave the NHS but want to return or stay to do so.” Read full story (paywalled) Source: The Telegraph (20 August 2022)
  20. News Article
    An LMC has created template letters to help practices reject secondary care workload dumping, including rejected referrals and requests to complete work on behalf of hospital trusts. Cambridge LMC said it developed the tools amid a growing ‘tsunami’ of secondary care workload transfer into general practices. One template letter tackles the rejection of a referral ‘on the basis that a proforma was not enclosed or completed in full’. It points out that the GMC requires GPs to refer when they ‘believe it is necessary to do so’ and that their ‘contractual obligations make no mention of a requirement to complete a proforma’. Cambridgeshire LMC chief executive Dr Katie Bramall-Stainer told Pulse that ‘we need the temperature to rise on the understanding around pressures across general practice’. Read full story For more information on the issues raised, read a blog by Patient Safety Learning about the patient safety risks of rejected outpatient referrals. Source: Pulse (19 August 2022)
  21. News Article
    An immunologist has warned the new strain of Covid-19 could be causing different symptoms – including one that emerges during the night. Omicron BA.5 is a highly-contagious subvariant prompting concern as it contributes to a fresh wave of infections across the globe, including the UK. Scientists have been finding differences with previous strains, including the ability to reinfect people within weeks of having Covid. “One extra symptom from BA.5 I saw this morning is night sweats,” Professor Luke O’Neill from Trinity College Dublin told an Irish radio station in mid-July. Read full story Source: The Independent (24 August 2022)
  22. Content Article
    Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in healthcare systems across the world. In recognition of this, in 2017 the World Health Organization (WHO) launched the Third WHO Global Patient Safety Challenge: Medication Without Harm, aimed at improving medication safety. This article provides information and resources related to the Challenge.
  23. News Article
    Nearly 700 doctors are likely to leave the Welsh NHS as a result of a recent 4.5% pay rise, the British Medical Association has warned. The warning follows a survey by BMA Cymru, in which more than half of the 1,397 respondents said they could leave and most felt morale had dropped. The below-inflation pay rise will apply to consultants, junior doctors and GPs. The Welsh government said it accepted the NHS pay review body's advice and was limited on how far it could go. Dr Iona Collins, chairwoman of the BMA's Welsh Council, said the findings resonated with what she was hearing from colleagues across Wales. "Doctors' take-home pay has reduced over several years, making the NHS an increasingly unattractive employer," said Dr Collins. Read full story Source: BBC News (23 August 2022)
  24. Content Article
    In this blog for The King's Fund, Richard Murray examines the issues that are pushing the NHS into crisis and causing the lowest levels of public satisfaction since the 1990s. The primary cause of this emergency is the workforce crisis, an existing trend that has been accelerated by the Covid-19 pandemic. He examines the approaches that have been taken to similar crises in the past, and highlights the importance of the workforce plan that is due to be released by NHS England and Health Education England towards the end of the year.
  25. Content Article
    This statement from Chair Peter Wyman addresses allegations of bullying and racism within NHS Blood and Transplant as reported in The Times on 21 August 2022. In the statement, Peter Wyman says, "I cannot overstate the importance we place in ensuring we have a strong, positive and inclusive culture so we can serve the public and patients who need us.  “Issues of racism and bullying came to light in parts of our organisation two years ago after an in-depth staff listening exercise. We’ve moved on a lot in the past two years. Our actions have included providing a safe way for staff to raise and discuss issues by appointing a Freedom to Speak Up Guardian, improving recruitment processes to be more inclusive, matured how we manage conflict and grievances and refreshing our code of conduct so we all know the behaviours that are expected of us. We continue to measure progress through ongoing staff engagement.   “We are making progress but like every good organisation we should always be challenging ourselves to do even better. In particular, I want to ensure we have a culture that enables each of us to be our best, that encourages everyone to speak up without fear or favour if they see something wrong or something which might be done better. I want a culture where everyone is valued for who they are and what they contribute. "There can be no place for any form of discrimination, bullying or harassment.”
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