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News Article
A nurse-led trial has found that a new electronic tool could reduce the number of preventable injuries and deaths caused by wrongly inserting nasogastric tubes. The study, led by Tracy Earley, a consultant nutrition nurse at Royal Preston Hospital, tested a new fibre-optic device which can tell clinicians definitively if a nasogastric tube – which is inserted through the nose and delivers food, hydration and medicine into the stomach – has been placed correctly. Currently, to check if nasogastric tubes – also referred to as NG tubes – are in the right place, nurses have to extract bodily fluid from the patient through the tube. Clinicians then test this fluid on a pH strip to judge whether the placement is correct. Studies show that interpreting the pH level results in mistakes 12-30% of the time, and that in 46% of cases nurses are unable to draw aspirate at all. This means patients have to undergo x-rays, leaving them without nutrition or treatment for longer. The study tested a device called NGPod, which uses a fibre-optic sensor to retrieve the pH reading from the tip of the NG tube leading to a definitive 'yes' or 'no' result in terms of whether it has been placed correctly – removing the need for aspirate or interpretation from the health professional. It found that the device was as accurate as pH strip testing, and removed all of the risks associated with making subjective pH strip judgements. Read full story Source: Nursing Times, 18 July 2023- Posted
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- Nurse
- Medical device / equipment
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Event
Scottish Speak Up Conference
Sam posted an event in Community Calendar
This conference is for staff involved in managing concerns in NHS Scotland, including the promotion, delivery, and use of the Whistleblowing Standards. The Independent National Whistleblowing Office are supporting the event. It will explore the legislative requirements around whistleblowing and the benefits of effective management of concerns. The programme concludes with a focus on what a healthy speak up culture looks like and how that can be delivered. The day will be chaired by John Sturrock, KC, and include a keynote presentation from Rosemary Agnew, the Independent National Whistleblowing Officer. It also brings together expert speakers from NHS Scotland, Scottish Government, trade union and academia with expertise in speaking up, culture change, quality, safety and candour. The programme will consider the Whistleblowing Standards since their launch in April 2021, as they approach their anticipated 3-year review. It offers an opportunity to share good practice, support ongoing improvements and promote an effective Speak Up culture that works from the bedside to the boardroom. Programme Register- Posted
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- Speaking up
- Whistleblowing
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News Article
NHS mental health services are stuck in a “vicious cycle” of short staffing and overwhelming pressures, a government committee has warned. Rising demand for mental health services has “outstripped” the number of staff working within NHS organisations, according to the public accounts committee. A report from the committee warned that ministers must act to get services out of a “doom loop” in which staff shortages is hitting morale and leading people to quit the already-stretched services. It found staffing across mental health services has increased by 22% between 2016 and 17 and 2021 and 22 while referrals for care have increased by 44% over the same period. Healthcare leaders warned there are 1.8 million people on the waiting list for NHS mental health care with hospital bosses “deeply concerned”. Read full story Source: The Independent, 21 July 2023- Posted
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- Leadership
- Mental health
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News Article
The government has admitted that many ‘vulnerable’ hospitals ‘suffer with a lack of permanence of leadership’, but said that chiefs are only sacked by NHS England ‘in extreme and exceptional circumstances’. The comments were included in the government’s response to the independent investigation into major maternity care failures at East Kent Hospitals University Foundation Trust, which highlighted how the practice of repeatedly hiring and firing leaders had contributed to its problems. The investigation said successive chairs and CEOs at the FT were “wrong” to believe it provided adequate care, and urged that they be held accountable. But it said senior management churn had been “wholly counterproductive”, and that it had “found at chief executive, chair and other levels a pattern of hiring and firing, initiated by NHS England” which would “never have been an explicit policy, but [had] become institutionalised”. Read full story (paywalled) Source: HSJ, 21 July 2023- Posted
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- Leadership
- Organisational culture
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News Article
More than 250,000 dementia patients could miss out on new treatments for the disease because they do not have a formal diagnosis, according to government figures. NHS data published for the first time shows the prevalence of different types of dementia with which people in England have been diagnosed. Dementia is an umbrella term for many different conditions, affecting more than 55 million people worldwide. This week, health regulators were urged to approve two new game-changing dementia drugs, after a landmark study confirmed that donanemab slowed cognitive decline in Alzheimer’s patients by 35%, while last year, a second drug, lecanemab, was found to reduce the rate by 27%. The NHS primary care dementia figures estimate that there are about 708,000 people over 65 with dementia in England, but only about 450,000 have a recorded diagnosis. That means that more than 250,000 are missing out on these potential new treatments. Read full story Source: The Guardian, 20 July 2023 -
News Article
The adoption of artificial intelligence (AI) by the NHS should be faster, and more frameworks should be in place to get emerging technologies to as many patients as possible, experts have told MPs. A number of senior figures from medicine and biotechnology gave evidence to the Health and Social Care Committee as part of its inquiry into cancer technology. Stephen Duffy, a professor of cancer screening at the Wolfson Institute of Population Health at Queen Mary University of London, told MPs there is “strong potential” for AI, particularly in areas such as reading mammograms for the breast screening programme. However, he warned that there will be “staff issues in terms of the number of staff needed to double-read mammograms”. He added: “Those issues aren’t going away. It seems to me that AI systems have already been shown to be very good in terms of detection of cancer on from mammograms, so they’re safe in that respect. Read full story Source: The Independent, 19 July 2023- Posted
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- AI
- Technology
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News Article
A trust has been accused of presiding over the deterioration of a key service amid communication problems between senior leaders and a ‘worrying series of resignations’ which has left the department with ‘no doctors’. The British Association of Dermatologists wrote to Worcestershire Acute Hospitals Trust on 13 July to request an urgent meeting with the provider’s management to discuss the matter. The letter, seen by HSJ, outlines fundamental patient safety and staffing concerns about the trust’s dermatology service and accuses the trust of putting “continued communication barriers” between clinicians and management. The letter, signed by BAD president Mabs Chowdhury, says there are now “no doctors in the department” after two consultants and a locum consultant resigned “due to apparent unhappiness with the running of services [and in] a continuation of a worrying series of resignations”. Read full story (paywalled) Source: HSJ, 19 July 2023- Posted
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- Organisation / service factors
- Doctor
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News Article
The majority of trust leaders have reported an increase in the ‘burden’ put on them by regulators, citing more demanding ‘ad hoc’ requests during heightened operational pressure. In NHS Providers’ latest survey of NHS trust leaders’ experiences of regulation, a little over half of respondents – 52% – said the burden from NHS England and the Care Quality Commission had increased in the past year. The percentage was higher among acute/community and community trusts, and all ambulance and specialist trust respondents said the burden had increased. An even higher overall share of trusts – 59% – said “ad hoc requests” from regulators had increased during the same time period. This includes requests for information or meetings at short notice, diverting staff from day-to-day operational duties. Read full story (paywalled) Source: HSJ, 20 July 2023- Posted
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- Regulatory issue
- Organisation / service factors
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News Article
The trust at the centre of a maternity scandal insists it has been providing immediate anaesthetic cover for obstetric emergencies, contrary to an NHS England report suggesting it had not and had been potentially breaching safety standards. Health Education England – now part of NHSE – visited William Harvey Hospital in March and was told senior doctors in training who were covering obstetrics could also be covering the cath lab – which deals with patients who have had a heart attack, and could receive trauma, paediatric emergency and cardiac arrest calls. This suggested the trust was in conflict with Royal College guidelines which state an anaesthetist should always be “immediately available” for obstetrics. East Kent Hospitals University Foundation Trust, which runs the hospital, originally told HSJ its rota had very recently been changed and that an anaesthetist with primary responsibility for maternity could leave any other work to attend to a maternity emergency immediately. However, it has since said it has been the case for a long time that an anaesthetist is available to return to maternity in case of an emergency. Read full story (paywalled) Source: HSJ, 17 June 2023 -
Event
HSIB: After Action Review course
Sam posted an event in Community Calendar
This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. You’ll also be directed to specific activities designed to extend and consolidate your knowledge. Register- Posted
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- PSIRF
- After action review
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Event
HSIB: After Action Review course
Sam posted an event in Community Calendar
This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. You’ll also be directed to specific activities designed to extend and consolidate your knowledge. Register- Posted
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- Investigation
- Patient safety incident
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Event
HSIB: After Action Review course
Sam posted an event in Community Calendar
This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. You’ll also be directed to specific activities designed to extend and consolidate your knowledge. Register- Posted
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- After action review
- Investigation
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(and 2 more)
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Event
HSIB: After Action Review course
Sam posted an event in Community Calendar
This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. You’ll also be directed to specific activities designed to extend and consolidate your knowledge. Register- Posted
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- After action review
- Investigation
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(and 2 more)
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News Article
Staff fell asleep while on duty at a mental health trust, inspectors found. The Care Quality Commission (CQC) said it was "very disappointed" to find patient safety being affected by the same issues it had seen previously. It said on acute wards for adults of working age and psychiatric intensive care units, five patients described staff falling asleep at night. Despite CCTV being available, managers told the CQC they could not always immediately prove staff had been sleeping as accessing the pictures could take up to a fortnight. The CQC report added trust data from June to December 2022 recorded 20 incidents of staff falling asleep while on duty but no action was taken because the video evidence had not been viewed. Rob Assall, the CQC's director of operations in London and the East of England, said: "When we inspected the trust, we were very disappointed to find people's safety being affected by many of the same issues we told the trust about at previous inspections. "This is because leaders weren't always creating a culture of learning across all levels of the organisation, meaning they didn't ensure people's care was continuously improving or that they were learning from events to ensure they didn't happen again." Read full story Source: BBC News, 12 July 2023- Posted
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- Mental health
- Staff factors
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News Article
A scheme in which ‘category 2’ 999 calls are validated by clinicians will be extended nationally after reducing journeys by 4%in a pilot, with no adverse incidents, NHS England has told HSJ. NHSE also confirmed that one ambulance trust in the scheme, the West Midlands, has begun delaying the dispatch of ambulances for some category 2 calls by up to 23 minutes so that the validation can take place. At three other trusts – London, South Western and the East Midlands – about 40% of category 2 calls receive clinical validation, but an ambulance is dispatched to them as soon it is available, as normal. Officials said they believe the demand benefit could be greater if ambulance trusts are able to devote more clinical capacity to the validation process. About 40% of category 2 calls are judged suitable for validation, but not all of them complete the process before an ambulance arrives. Read full story (paywalled) Source: HSJ, 11 July 2023 -
Event
This national conference looks at the practicalities of Serious Incident Investigation and Learning from Deaths in Mental Health Services and implementation of the New Patient Safety Incident Response Framework (PSIRF previously known as the Serious Incident Framework). The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-of-deaths-serious-incidents-in-mental-health-services or email [email protected] hub members receive 20% off. Email [email protected] for discount code. Follow this conference on Twitter @HCUK_Clare #SIMental- Posted
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- Patient death
- Patient safety incident
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Event
Deprivation of liberty safeguards: Moving forward
Sam posted an event in Community Calendar
The Department of Health and Social Care announced on the 5th April 2023 that the implementation of the Liberty Protection Safeguards will be delayed until at least the next general election (anticipated to be in Autumn 2024). With the delay to the Liberty Protection Safeguards it is more important than ever to ensure the existing scheme of Deprivation of Liberty Safeguards (DoLS) works, that providers understand the application of Deprivation of Liberty Safeguards and interaction with the Mental Capacity Act. It has been widely recognised that there are number of challenges associated with the current DoLS system, particularly in light of the increases in the number of DoLS applications – which have been seen across England and Wales. In light of the UK Government decision, we will need to consider how we strengthen the current DoLS system in order to continue to protect and promote the human rights of those people who lack mental capacity. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/liberty-protection-safeguards-mca or email [email protected]. hub members receive 20% off. Email [email protected] for discount code. Follow the conference on Twitter @HCUK_Clare #LPS2023 -
Event
How to deal with difficult people
Sam posted an event in Community Calendar
This one day virtual masterclass facilitated by Mr Perbinder Grewal, will focus on how to deal with difficult people. Do you have someone at work who consistently triggers you? Doesn’t listen? Takes credit for work you’ve done? Wastes your time with trivial issues? Acts like a know-it-all? Can only talk about themselves? Constantly criticises? We will discuss strategies and tools to improve communication and interactions with others. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/how-to-deal-with-difficult-people or email [email protected]. hub members receive a 20% discount. Email [email protected] for discount code.- Posted
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- Personal development
- Communication
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Event
Error and systems-based solutions to patient safety
Sam posted an event in Community Calendar
This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/systems-based-solutions-patient-safety-masterclass or email [email protected]. hub members receive a 20% discount. Email [email protected]- Posted
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- Human factors
- Human error
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Event
Patient Safety Incident investigations
Sam posted an event in Community Calendar
The Patient Safety Strategy (2019) and Patient Safety Investigation Framework (PSIRF) both outline a fundamental shift in the way that patient safety investigations are conducted. This ‘new era’ in patient safety represents a considerable shift in the way that investigations are conducted, particularly for those NHS Trusts implementing PSIRF. As the Serious Incident Framework (2015) becomes obsolete, how teams select their incidents to investigate will shift away from severity of harm to focusing on pinpointing opportunities to maximising learning. Indeed, under the new arrangements, teams are encouraged to consider utilising a wider range of investigation techniques that will ensure a more proportionate and potentially less time-consuming approach to understanding sub-standard care and failings. With an emphasis on systems thinking and human factors, organisations will need to identify and train expert investigators. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/psirf-masterclass or click on the title above or email [email protected]. hub members receive a 20% discount. Email [email protected] for discount code.- Posted
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- Patient safety incident
- PSIRF
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(and 1 more)
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Event
Systems approach to patient safety including Human Factors
Sam posted an event in Community Calendar
This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/systems-approach-patient-safety-masterclass or email [email protected]. hub members receive a 20% discount. Email [email protected] for discount code.- Posted
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- System safety
- Human factors
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(and 1 more)
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Event
The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework. This national conference looks at the practicalities of Serious Incident Investigation on and Learning and how this has changed with the publication of PSIRF. The conference will also update delegates on best practice in serious incident investigation under PSIRF and ensuring the focus is on learning from improvement. There will also be a extended focus on learning, including mortality governance and learning from deaths ensuring insight and investigation findings lead to improvement. The conference will include updates from PSIRF early adopter sites. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email [email protected]. hub members receive a 20% discount. Email [email protected] for discount code. Follow on Twitter @HCUK_Clare #NHSSeriousIncidents- Posted
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- Patient safety incident
- Investigation
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(and 1 more)
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Event
This masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key learning objectives: Understanding the role of the Senior Information Risk Owner Identifying Information Risks across the organisation Working with others to mitigate the risk to patients, staff and organization. Confidence that all reasonable technical and organisation measure are in place Giving assurance to the Board that risks have been considered, mitigated or owned Understand the requirements of external confidence that policies, procedures are in place to deal with Data Breaches. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/masterclass-developing-your-role-as-a-senior-information-risk-owner-siro or email [email protected]. hub members receive a 20% discount. Email [email protected] for a discount code.- Posted
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- Risk assessment
- Risk management
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(and 1 more)
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News Article
An inspection of an ‘outstanding’ hospital has revealed concerns about unsafe staffing, as well as bullying and undermining behaviour. The then Health Education England issued Frimley Health Foundation Trust 14 mandatory requirements after visiting its Frimley Park Hospital in March to look at training in medical specialties. The risk-based review followed concerns in the 2022 national training survey and previous quality interventions by HEE. Among the problems HEE was told about were: Junior doctors feeling staffing on some shifts was unsafe. Foundation year one doctors were sometimes the only doctors on a ward, while one foundation doctor spent their first weekend on call looking after two wards by themselves. Concerns about bullying and undermining behaviour in an unnamed department, and consultant behaviour during weekend handover which left some staff feeling “uncomfortable”. Read full story (paywalled) Source: HSJ, 11 July 2023- Posted
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- Safe staffing
- Bullying
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Event
untilThe final tweetchat in the 'Six lessons for leading improvement' campaign.