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Sam

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  • First name
    Samantha
  • Last name
    Warne
  • Country
    United Kingdom

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  • About me
    Lead Editor for the hub
  • Organisation
    Patient Safety Learning
  • Role
    Editor

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  1. News Article
    Newborn babies could be at a higher risk of a deadly bacterial infection carried by their mothers than previously thought. Group B Strep or GBS is a common bacteria found in the vagina and rectum which is usually harmless. However, it can be passed on from mothers to their newborn babies leading to complications such as meningitis and sepsis. NHS England says that GBS rarely causes problems and 1 in 1,750 babies fall ill after contracting the infection. However, researchers at the University of Cambridge have found that the likelihood of newborn babies falling ill could be far greater. They claim one in 200 newborns are admitted to neonatal units with sepsis caused by GBS. Pregnant women are not routinely screened for GBS in the UK and only usually discover they are carriers if they have other complications or risk factors. Jane Plumb, co-founded charity Group B Strep Support with her husband Robert after losing their middle child to the infection in 1996. She said: “This important study highlights the extent of the devastating impact group B Strep has on newborn babies, and how important it is to measure accurately the number of these infections. “Inadequate data collected on group B Strep is why we recently urged the Government to make group B Strep a notifiable disease, ensuring cases would have to be reported. “Without understanding the true number of infections, we may not implement appropriate prevention strategies and are unable to measure their true effectiveness.” Read full story Source: The Independent, 29 November 2023 Further reading on the hub: Leading for safety: A conversation with Jane Plumb, Founder of Group B Strep Support
  2. News Article
    Patients are at risk of having serious health conditions missed because of the lack of continuity of care provided by GPs, the NHS safety watchdog says. Investigators highlighted the case of Brian who was seen by eight different GPs before his cancer was spotted as an example of what can go wrong. Brian had a history of breast cancer and had been discharged from the breast cancer service. Two years later he began to have back pain. Over the following eight months, he saw two out-of-hours GPs and six GPs based at his local practices as well as a physio and GP nurse, before he was sent for a hospital check-up in late 2020. A secondary cancer had developed on Brian's spine, but it was too late to offer him curative treatment and he was given end-of-life care. He has since died. The watchdog said the lack of continuity of care resulted in the diagnosis of Brian's cancer being missed. One of the key problems was that the different GPs he saw missed the fact he was attending repeatedly for the same issue. Senior investigator Neil Alexander said Brian's case was a "stark example" of what can happen when there is a breakdown in continuity of care. "He told our team 'when I am gone, no-one else should have to go through what I did'." Read full story Source: BBC News, 30 November 2023
  3. News Article
    The number of people with norovirus in hospital in England is 179% higher than the average at this time of year, official data shows, as the NHS comes under mounting winter pressure. Admissions caused by the vomiting and diarrhoea-causing norovirus have surged and cases of other seasonal viruses are also rising, according to NHS England figures. Health chiefs said the impact on hospitals from seasonal viruses was likely to be worsened by the current cold weather. “We all know somebody who has had some kind of nasty winter virus in the last few weeks,” said Sir Stephen Powis, NHS England’s medical director. “Today’s data shows this is starting to trickle through to hospital admissions, with a much higher volume of norovirus cases compared to last year, and the continued impact of infections like flu and RSV in children on hospital capacity – all likely to be exacerbated by this week’s cold weather.” Read full story Source: The Guardian, 30 November 2023
  4. Event

    IHI Forum

    Sam
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    The IHI Forum is a four-day conference that has been the home of quality improvement in health care for more than 30 years. Dedicated improvement professionals from across the globe will be convening to tackle health care's most pressing challenges: improvement capability, patient and workforce safety, equity, climate change, artificial intelligence, and more. Register
  5. Event
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    The Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Further speakers TBC Register
  6. Event
    The Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Further speakers TBC Register
  7. Event
    until
    The Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Further speakers TBC Register
  8. Event
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    NHS Resolution’s Safety and Learning team, are hosting a virtual forum on perspectives on delivering health in the prison and justice system. The purpose is to raise awareness of the cost and scale of harm, discuss the realities, best practice, challenges and recommendations around collaborating to support healthcare delivery in the justice system. We will hear from a diverse range of experts in the field. The format is interactive, with presentations followed by questions and panel discussion. Event programme: Learning from prison claims - NHS Resolution The realities of delivering healthcare in prison - Practice Plus Group Good practice and themes from inspections - HM Inspectorate of Prisons The medico-legal aspect of prison health claims - Bevan Brittan Q&A panel discussion. Register
  9. News Article
    HSJ analysis of the NHS England data also found that 19,000 adults with a serious mental illness are waiting for longer than 18 months for a second contact with community mental health services. This is seen as a more meaningful metric for adults than the first contact. In total, almost 240,000 children and young people were waiting for treatment from community mental health services in August 2023, as well as more than 192,000 adults. The data revealed the median, or typical, waiting time for children and young people from referral to first contact was 178 days. The median wait time for adults from referral to “second contact” was 120 days. The NHS long-term plan set out proposals for a four-week waiting time standard for children and adults to access community mental health services. This approach was piloted and a consultation published, but the new standards are yet to be implemented. Sean Duggan, chief executive of the mental health network at the NHS Confederation, said leaders would be concerned – although “not surprised” – that patients were waiting so long for community services. He added: “We need access and waiting times standards for all mental health services, to help us improve national data and to direct and allocate resources effectively.”
  10. News Article
    World leaders, cervical cancer survivors, advocates, partners, and civil society came together last week to mark the third Cervical Cancer Elimination Day of Action. The Initiative, which marked the first time Member States adopted a resolution to eliminate a noncommunicable disease, has continued to gain momentum, and this year's commemoration promises to be a beacon of hope, progress, and renewed commitment from nations around the world. “In the last three years, we have witnessed significant progress, but women in poorer countries and poor and marginalized women in richer countries still suffer disproportionately from cervical cancer,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “With enhanced strategies to increase access to vaccination, screening and treatment, strong political and financial commitment from countries, and increased support from partners, we can realize our vision for eliminating cervical cancer.” Australia is on target to be among the first countries in the world to eliminate cervical cancer, which the country anticipates to achieve in the next 10 years. In Norway, researchers have recently reported finding no cases of cervical cancer caused by the human papillomavirus (HPV) in 25-year-olds, the first cohort of women who were offered the vaccine as children through the national vaccination programme. Indonesia announced this week a declaration committing to reach the 90-70-90 targets for cervical cancer elimination through the national cervical cancer elimination plan (2023 to 2030). In the United Kingdom, England’s National Health Service (NHS) pledged this week to eliminate cervical cancer by 2040. Read full story Source: WHO, 17 November 2023
  11. News Article
    Patient safety is being put at risk by the “toxic” behaviour of doctors in the NHS, the health ombudsman has said. Rob Behrens, who investigates complaints about the NHS in England, warned that the hierarchical and high-handed attitude of clinicians was undermining the quality of care in some hospitals. He called for medical training to be redesigned to encourage a more empathetic and collaborative approach from doctors. Pointing to failings in the treatment of sepsis and the problems in maternity services, Behrens said he was “shocked on a daily basis” by what he saw as ombudsman. Too often, “organisational reputation has been put above patient safety”, he told The Times Health Commission. The ombudsman warned of a “Balkanisation” of health professionals, with rivalries between doctors and nurses or midwives and obstetricians harming patient care. “For all the brilliance of clinicians quite often they’re not very good at working together,” he said. “Time and again, the handover from one clinician to another, from one shift to another, or the inability to raise the issue at a senior level has been a key factor in what has gone wrong.” Read full story (paywalled) Source: The Times, 18 November 2023
  12. News Article
    Two young people facing mental health crises were left on paediatric wards for months while different agencies across a health system struggled to find appropriate placements. The patients – who were both autistic and had learning disabilities, with special educational needs – were admitted to Maidstone and Tunbridge Wells Trust (MTW) last year after attending emergency departments more than 10 times within a two-month period. They were left on a paediatric ward – one of the patients for four months – as this was the “only available place of safety as opposed to the optimum setting to meet their needs,” according to Kent and Medway Integrated Care Board’s “learning review” of children and young people with complex needs, which the two cases prompted. The review, which HSJ obtained under a Freedom of Information request, revealed several problems with joint working, despite a multidisciplinary team meeting regularly to discuss the young patients’ needs. Since the review, a new escalation process has been introduced, urgent mental health risk assessments in the community have been enhanced and a three-month pilot of a self-harm service has been implemented at Tunbridge Wells Hospital, part of MTW. Read full story (paywalled) Source: HSJ, 17 November 2023
  13. Event
    until
    The Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Further speakers TBC Register
  14. Event
    until
    The Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Further speakers TBC Register
  15. Event
    until
    The Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Peter Ledwith, Deputy Director of Governance, East Cheshire NHS Trust Liam Oliver, Senior Patient Safety Manager, Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board Register
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