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About Sam

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    United Kingdom

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    Lead Editor for the hub
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    Patient Safety Learning
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  1. Event
    How looking after staff health and well-being contributes to patient safety. "It’s about a work place that’s more respectful, inclusive and open as a means of creating safety”. Martin Bromiley OBE To deliver high-quality care, the NHS needs staff that are healthy, well and at work. A challenge highlighted further by the pandemic. Join the Clinical Human Factors Group (CHFG) for short and lively presentations, questions and panels with: Rt Hon Jeremy Hunt MP Chair of the Commons Health and Social Care Select Committee Suzette Woodward - culture, conditions and values Scott Morrish - the legacy of avoidable harm Dr Henrietta Hughes OBE – speaking up, culture change and well-being Prof. Jill Maben - staff well-being and patient experience Aliya Rehman – NHS Employers - the well-being framework Mark Young – Learning from the rail industry - team dynamics Ed Corbett – Health & Safety Executive – Sustainable health and safety improvement Alice Hartley – Royal College of Surgeons Edinburgh – undermining and bullying – the team, individual and the patient Register
  2. News Article
    A review of a clinical commissioning group has discovered “microaggressions and insensitivities” towards Black, Asian and minority ethnic staff, and the use of derogatory slurs about other groups. The report into Surrey Heartlands CCG also uncovered incidents of shouting, screaming and bullying among other inappropriate behaviour. And it was reported some staff were unwilling to accept Black Lives Matter events as important, stating “all lives matter”. The review also discovered a culture of denial and turning a blind eye to consistent concerns, with staff fearful of speaking up. In particular, the HR department was said to have been repeatedly told about the behaviour of one staff member but had chosen to ignore or delay dealing with the issues. However, the review found “no evidence for widespread discriminatory practices” and “no clear evidence for a widespread culture of bullying and ill-treatment” — but it added the systems to deal with concerns had failed and there was a sense of “organisational inaction”. Read full story (paywalled) Source: HSJ, 27 November 2020
  3. News Article
    A woman has become blind after her monthly eye injections were delayed for four months during lockdown. Helen Jeremy, 73, said everything she enjoyed doing has "gone out of the window" after losing her eyesight. She has glaucoma and was diagnosed with age-related macular degeneration four years ago. Monthly injections controlled the condition and meant she could still drive and play the piano. However, her appointments were cancelled when the pandemic struck and her eyesight deteriorated. "I was panicking. It was terrifying. Because I'm a widow I'm on my own and it was awful," she said. "Suddenly my eyesight was basically gone. By the time of my next appointment I was told there was no point in going on with these injections because the damage had been done to the back of my eye." Thousands more people in Wales are at risk of "irreversible sight loss" because of treatment delays, RNIB Cymru warns. The Welsh Government said health boards are working to increase services. Read full story Source: BBC News, 27 November 2020
  4. News Article
    The chairman of an inquiry that has confirmed a 20-year cover-up over the avoidable death of a baby has warned there are other families who may have suffered a similar ordeal. Publishing the findings of his investigation into the 2001 death of Elizabeth Dixon, Dr Bill Kirkup said he wanted to see action taken to prevent harmed families having to battle for years to get answers. Dr Kirkup, who has been involved in multiple high-profile investigations of NHS failures in recent years, said: “There has been considerable difficulty in establishing investigations, where events are regarded as historic. I don't like the term historic investigations. I think that these things remain current for the people who've suffered harm, until they're resolved, it’s not historic for them. “There has been significant reluctance to look at a variety of cases. Mr and Mrs Dixon were courageous and very persistent and they were given help by others and were successful in securing the investigation and it worries me that other people haven't been. “I do think we should look at how we can establish a proper mechanism that will make sure that such cases are heard." “It's impossible to rule out there being other people who are in a similar position. In fact, I know of some who are. I think it's as important for them that they get heard, and that they get things that should have been looked at from the start looked at now, if that's the best that we can do.” Read full story Source: The Independent, 27 November 2020
  5. News Article
    A blood test designed to detect more than 50 types of cancer at an early stage will be trialled by the NHS. More than 165,000 people in England will be offered the tests from next year. If successful, the NHS hopes to expand it to 1m people from 2024. Sir Simon Stevens, NHS England chief executive, said early detection had the potential "to save many lives". While some welcomed the pilot, others cautioned the test was still untried and untested. Developing a blood test for cancer has been keeping scientists busy for many years without much success. Making one that's accurate and reliable has proved incredibly complex - the danger is that a test doesn't detect a person's cancer when they do have it, or it indicates someone has cancer when they don't. This test, developed by the Californian firm Grail, is designed to detect molecular changes in the blood caused by cancer in people with no obvious symptoms. As part of a large-scale pilot, also funded by the company, 140,000 participants aged between 50 and 79 will be asked to take the tests for the next three years. Another 25,000 people with possible cancer symptoms will also be offered testing after being referred to hospital in the normal way. Read full story Source: BBC News, 27 November 2020
  6. News Article
    A transgender boy is taking NHS England to court over delays in accessing gender identity treatment. The 14-year-old, who was referred to the UK’s only youth gender identity clinic in October 2019, has been told he may have to wait at least another year to be seen. He said he was experiencing “fear and terror” while he waits for treatment. Young people are currently facing “extensive waits” to see a therapist, with the average delay being 18 months or more, according to the Good Law Project, which is representing the boy. The not-for-profit organisation said the health service was legally required to ensure patients referred to gender identity development services (GIDS) are seen within 18 weeks. Gender clinics for adults across the country have reported similar delays, with the Devon Partnership NHS Trust reporting “lengthy waiting times” while the Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust said patients were facing delays “in excess of 32 months” for an initial appointment and 62 months from referral to treatment. Trusts have blamed a surge in demand as well as reduced capacity, including staffing problems. The teenager involved in the case said in a statement: “The length of the NHS waiting list means the treatments which are essential for my well being are not available to me." “By the time I get to the top of the list it will be too late, and in the meantime I suffer the fear and terror that gender dysphoria causes, every day.” Read full story Source: The Independent, 23 November 2020
  7. News Article
    Staff at a specialist care unit did not attempt to resuscitate a woman with epilepsy, learning difficulties and sleep apnoea when she was found unconscious, an inquest heard. Joanna Bailey, 36, died at Cawston Park in Norfolk on 28 April 2018. Jurors heard she was found by a worker whose CPR training had expired, and the private hospital near Aylsham - which care for adults with complex needs - had been short-staffed that night. Support worker Dan Turco told the coroner's court he went to check on Ms Bailey just after 03:00 BST and found she was not breathing and had blood around her mouth. The inquest heard he went to get help from colleagues, including the nurse in charge, but no-one administered CPR until paramedics arrived. It was heard Mr Turco's CPR training had lapsed in the weeks before Ms Bailey died, unbeknown to him. Mr Turco said he had since received training and has had his first aid qualifications updated. Cawston Park, run by the Jeesal Group, a provider of complex care services within the UK, is currently rated as "requires improvement" by the Care Quality Commission. Read full story Source: BBC News, 23 November 2020
  8. News Article
    Up to £20 million is available for new research projects which aim to understand and address the longer-term physical and mental health effects of COVID-19 in non-hospitalised individuals. Increasing medical evidence and patient testimony has shown that some people who contract and survive COVID-19 may develop longer-lasting symptoms. Symptoms can range from breathlessness, chronic fatigue, ‘brain fog’, anxiety and stress and can last for months after initially falling ill. These ongoing problems, commonly termed ‘Long-COVID’, may be experienced by patients regardless of how severe their COVID-19 infection was and irrespective of whether they were hospitalised. UK Research and Innovation (UKRI) and the National Institute for Health Research (NIHR) are launching a call to fund two or three ambitious and comprehensive proposals and a small number of study extensions that will address ‘Long-COVID’ in the community. This work will complement other major studies already funded by UKRI and NIHR which focus on long covid in hospitalised patients. Projects are expected to start early in the new year and may be funded for up to three years in the first instance. The call will open on 12 November and close on 9 December 2020. Further information
  9. News Article
    News that the Medicines and Healthcare products Regulatory Agency (MHRA) will review the data from trials of one of the most promising COVID-19 vaccine candidates, to see whether it meets the agency’s robust standards of quality, safety and effectiveness, has been welcomed by the UK Government. Initial data had shown the Pfizer/BioNTech vaccine is 94% effective in protecting people over 65 years of age from coronavirus, with no serious safety concerns having been raised during the clinical trials. Already the UK Government has pre-ordered 40 million vaccine doses – enough to provide vaccinations for up to a third of the population – and is expected to receive the total amount by the end of 2021. The majority of doses are anticipated to be received in the first half of next year. As well as successfully protecting those over the age of 65, trial data also showed that the vaccine candidate also performed equally well in people of all ages, races and ethnicities. Approval from the MHRA, as the UK’s independent regulator, is required for the COVID-19 vaccine to be authorised for consistent manufacture and supply. To achieve this approval, it must demonstrate that it meets strict quality, safety and effectiveness standards set by the MHRA. Business Secretary Alok Sharma added: “Today, we have renewed hope that we are on the brink of one of the most significant scientific discoveries of our time, as we reach the crucial last stage to finding a COVID-19 vaccine. “While this news is a cause for celebration, we must make sure that this vaccine, like all new medicines, meets standards of quality, safety, and effectiveness." Read full story Source: National Health Executive, 24 November 2020
  10. Event
    Join Dr Tanya Uritsky, clinical pharmacy specialist in pain stewardship at the Hospital of the University of Pennsylvania, where she will identify risk factors for opioid-induced respiratory depression in hospitalised surgical patients, define opioid tolerance, recognise other CNS depressants that can potentiate opioid-induced sedation and respiratory depression, and recommend an appropriate opioid starting dose for an opioid naïve perioperative patient. Opioid stewardship is the appropriate use of opioids and is an important part of patient safety. The highest risk for the development of opioid-induced respiratory depression is during the first 24 hours post-operatively. Knowing the best practices for pain management in the perioperative period, including how to identify a patient at increased risk for opioid-related adverse events, can help to improve patient safety. This session will provide insights into patient-related risk factors and considerations for pain management in the perioperative period. Register
  11. Event
    As we continue to adjust to a new way of conducting business and with your safety in mind, the Patient Safety Authority are continuing their series of roundtable discussions to facilitate engagement between PA healthcare facilities. Instead of regional in-person events, the Engagement Roundtable series will be conducted virtually, with participation open statewide via Microsoft Teams. The Patient Safety Authority believes that in the age of social distancing, finding ways to stay connected with other patient safety professionals is more important than ever. The primary goal of these events is to facilitate the sharing and discussion of information in a collaborative environment for a range of patient safety topics. This session is intended to give hospitals and ambulatory surgery facilities an opportunity to discuss current topics of interest and issues of concern submitted by facilities. This session will lead off with a discussion of how facilities prepare for potential disasters in the OR and lessons learned from actual events, followed by a general discussion. Register
  12. Event
    Coping with complexity: how a human factors systems approach can support competency development for pharmacists. Support in clinical decision making is recognised as an educational development need for pharmacists. The health policy landscape puts the pharmacist in a central role for clinical management of long-term complex morbidities, making clinical decision making and taking responsibility for patient outcomes increasingly important. This is compounded by the COVID-19 pandemic, where healthcare environments have become more complex and challenging to navigate. In this environment, foundation pharmacists were unable to sit the GPhC registration assessment during the summer of 2020 but provisionally the registration assessment is due to take place online during the first quarter of 2021. In response to this, a suite of resources has been developed with collaboration between Chartered Institute of Ergonomics and Human Factors (CIEHF) and Health Education England (HEE). These resources are aimed in particular at early career pharmacists and their supervisors, especially those in foundation pharmacist positions managing the transition from education to the workplace environment. This session will act as the launch event for these resources and can support early career pharmacists and supervisors to navigate the CIEHF learning resources developed so far. Register
  13. Event
    In this regular roundup episode, the Royal Society of Medicine once again bring together an expert panel to answer the most popular questions viewers sent in but didn't have time to cover. The panel this month will include Professor Trish Greenhalgh, Professor of Primary Care Health Sciences at the University of Oxford, Professor Peter Openshaw, Professor of Experimental Medicine at Imperial College London, and Professor Walter Ricciardi, past President of the Italian National Institute of Health. Professor Sir Simon Wessely will chair the 45-minute session, posing the most popular unanswered audience questions from October and November to the expert panel. Register
  14. News Article
    Hospitals across England could see oxygen supplies at worse levels this winter than at the peak of the first coronavirus wave – when some sites were forced to close to new admissions. An alert to NHS hospitals this week warned that because of the rise in admissions of COVID-19 patients, there is a risk of oxygen shortages. Trusts have been ordered to carry out daily checks on the amount of oxygen in the air on wards to reduce the risk of catastrophic fires or explosions. The problem is not because of a lack of oxygen but because pipes delivering the gas to wards will not be able to deliver the volume of gas needed by all patients. This can trigger a cut-off in supply and a catastrophic drop in pressure, meaning patients would be denied the oxygen they need to breathe. Read full story Source: The Independent, 20 November 2020
  15. News Article
    A world-leading children’s hospital has been accused of a “concerted effort” to cover up the mistakes that led to the death of a toddler. Jasmine Hughes died at London’s Great Ormond Street Hospital aged 20 months after suffering acute disseminated encephalomyelitis (ADEM), a condition in which the brain and spinal cord are inflamed following a viral infection. Doctors said that her death in February 2011 had been caused by complications of ADEM. But an analysis of detailed hospital computer records shows the toddler died after her blood pressure was mismanaged – spiking when she was treated with steroids then allowed to fall too fast. Experts say this led to catastrophic brain damage. Although the detailed computer records were supplied to the coroner who carried out Jasmine’s inquest, crucial information concerning her blood pressure was not included in official medical records that should hold the patient’s entire clinical history. Dr Malcolm Coulthard, who specialises in child blood pressure and medical records examination, carried out the analysis of the files, comprising more than 350 pages of spreadsheets. Dr Stephen Playfor, a paediatric intensive care consultant, examined the computer records and came to the same conclusion as Dr Coulthard, that mismanagement of Jasmine’s blood pressure by Great Ormond Street and Lister Hospital, in Stevenage, was responsible for her death. Dr Coulthard told The Independent: “As a specialist paediatrician, it is with great regret and disappointment that I have concluded that the doctors' records in Jasmine Hughes’ medical notes fail to reflect the truth about her diagnosis and treatment.” Read full story Source: The Independent, 20 November 2020