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Found 35 results
  1. Content Article
    Key findings The increase in incidence of Type 1 diabetes observed in the first year of the Covid-19 pandemic was followed by a continuing increase in the numbers newly diagnosed with the condition in 2021/22. Almost all of those with Type 2 diabetes were overweight or obese, and almost half had a diastolic or systolic blood pressure in the hypertensive range Despite reductions in the percentages recorded as requiring additional support between 2020/21 and 2021/22, over a third of children and young people were assessed as requiring additional psychological support outside of multidisciplinary meetings Inequalities persist in terms of the use of diabetes related technologies in relation to ethnicity and deprivation. Recommendations Commissioners should ensure adequate staffing of full multidisciplinary diabetes teams to manage the increasing numbers of cases of Type 1 and Type 2 diabetes observed since 2020, who are trained to facilitate the optimal use of new diabetes-related technologies. Children and young people with Type 1 diabetes should have equitable access to diabetes care, irrespective of social deprivation, ethnicity or geography. They should be offered a choice of diabetes technology that is appropriate for their individual needs with families being made aware of the potential differences in outcome with different modalities of insulin delivery and blood glucose monitoring. Health checks for children and young people with diabetes are essential for early recognition of complications. The need for tests and the results should be clearly communicated to families as part of their individual care package, and completion rates of checks should be monitored through the year. Awareness of diabetes symptomatology amongst the public should be enhanced to avoid newly diagnosed children and young people presenting with Diabetic ketoacidosis (DKA). Studies should be funded to derive evidence for interventions supporting pre-diabetic children young people to avoid progression to Type 2 diabetes.
  2. Content Article
    The definition of ‘success’ for incontinence mesh surgery was based on The British Society of Urogynaecology (BSUG) ‘pad test question’, which looked at whether a woman was using fewer incontinence pads after surgery. Like most women who had a mesh sling for incontinence implanted, I passed this test with flying colours. But the complications I experienced as a result of the surgery were painful, debilitating and life-changing, an experience shared by thousands of women who have had a pelvic mesh implant. For both incontinence and prolapse mesh, outcome logging merely looked at whether the prolapse had been fixed and did not query the onset of new pain or complications. Lack of follow-up, data collection and recognition of mesh as the cause of women's symptoms when they present with complications has led to a gross underestimation of the scale of pelvic mesh-related harm. So the prospect of an audit that would look to remedy this was a positive one. In 2020, the final report of the Independent Medicines and Medical Devices Safety (IMMDS) Review, ‘First Do No Harm’, called for “a retrospective audit and follow-up of women who had pelvic mesh surgery in 2010,” to be conducted by NHS Digital. The report highlighted that this should provide “far greater detail on mesh complications in the decade after surgery,” and that NHS Digital should make “every effort” to obtain sufficient data.[1] On 5 December 2022, the Minister for Women, Maria Caulfield MP, confirmed in the Commons that an audit had been completed following the acceptance of the IMMDS Review’s recommendation and would be published in 2023.[2] However, the record later had to be corrected, as it became clear in a further parliamentary question that, contrary to the stated intention of NHS Digital who conducted the audit, “...only Hospital Episode Statistic data was used in the audit and no other data was employed. Patients were not contacted as part of this audit.”[3] History repeats itself - the NHS audits the same data I was horrified to find out that instead of making “every effort” to get accurate information, NHS Digital have simply repeated the same exercise they carried out in 2018 in their retrospective audit of annual Hospital Episode Statistics (HES) data on mesh implant procedures. For the 2023 audit, they used the same approach taken in the 2018 audit and exclusively used HES data. This approach was highlighted in ‘First Do No Harm’ as being “widely criticised for its omissions, [for example] lack of any private sector data and for its implied underestimate of long-term complications.”[1] I wrote to the Health and Social Care Select Committee on behalf of Sling the Mesh in December 2022 to highlight the shortcomings of using HES data in isolation.[4] The Committee shared our concerns, highlighting that: “Without records of which patient has undergone which procedure, or been prescribed which drug, the health system will continue to, in the words of the IMMDS review team, “fly blind”... Although the retrospective audit of mesh implants is an encouraging first step, it will be unlikely to reflect and take into account all of the adverse effects women have experienced due to the nature of data used in the audit. We therefore recommend that the Government consider an alternative strategy for how to proactively contact those who have had the procedure about their postoperative experiences and possible side effects.”[2] NHS Digital’s approach does not paint a true picture of the extent of the harm caused by pelvic mesh. There are many issues with using purely HES data for a mesh audit, namely that: HES data does not capture complications, as women have not been followed up and therefore the spectrum of suffering has not been logged. it does not take into account any data from GPs or primary care, where potentially thousands of women have sought help for their mesh complications. Most of these women will not yet have set foot in a hospital for consultation or treatment. it does not take into account data from private hospitals, which may be recorded differently or not have been logged at all. there are discrepancies in how pelvic mesh insertion and removal is logged by different trusts and healthcare professionals. HES data sometimes lacks necessary detail on the nature of treatment. For example, until recently, there was no specific HES code for rectopexy mesh insertion or removal, which means the specific issues associated with this surgery are difficult to identify through data. How should the Government conduct an audit of mesh patients? If the Government is serious about understanding the true extent of harm caused by pelvic mesh, it needs to contact all women who have had mesh surgery within a specific time period to establish whether they have had complications or injuries over the following years. Mesh has a ticking time bomb nature, in that it can be fine for many months or even years before causing problems like erosion, so this long term follow-up is crucial to gauge the extent of harm. Instead of using unreliable and incomplete data, an audit needs to take the approach of the Paterson Inquiry and recall all affected patients.[5] If the cost of such an exercise would be prohibitively high, they could take a sample of women from across the country and use their findings to estimate the extent and nature of harm caused by pelvic mesh. Why is a reliable pelvic mesh audit important? Being able to quantify the extent of the harm is important so that we can establish an accurate figure of risk; what percentage of women suffer harm due to pelvic mesh, and what is the likelihood of more of them developing complications in years to come? Until we have this knowledge, the Government and regulatory system can’t learn the necessary lessons from the mesh scandal to ensure other devices don’t cause this degree of harm. Health services will also continue failing women when they seek help for injuries and complications that are likely to have been caused by mesh. So many women have also been subject to the secondary harm of gaslighting and not having their symptoms taken seriously by healthcare professionals. Having accurate data on harm caused by mesh would help put an end to the healthcare system seeing women’s concerns as ‘hysterical hearsay’. It would also help women understand that their complications must be taken seriously and that their symptoms are not ‘all in their heads’. Why is the Government not pushing for an accurate audit? When compared to the Government response to Paterson, the retrospective mesh audit seems like a token effort. Why is the Government less willing to understand and tackle the issues associated with mesh complications? Perhaps because, rather than being the responsibility of “one bad apple”, the harm caused by pelvic mesh is the responsibility of a system that failed to research, regulate and monitor the effects of medical devices designed to be implanted inside people’s bodies. There is also the fact that knowing the true extent of the harm caused by pelvic mesh has the potential to create a huge financial burden, if the Government ever agrees to fulfil its responsibility to set up a Redress Agency for women harmed by pelvic mesh surgery. Related reading The difficulty of medical negligence cases and why financial redress from the Government is so important for mesh victims (17 January 2023) Doctors’ shocking comments reveal institutional misogyny towards women harmed by pelvic mesh - a Patient Safety Learning blog (19 July 2022) “There’s no problem with the mesh”: A personal account of the struggle to get vaginal mesh removal surgery (1 May 2022) References 1 First Do No Harm. The report of the Independent Medicines and Medical Devices Safety Review, 8 July 2020 2 Health and Social Care Select Committee: Follow-up on the IMMDS report and the Government’s response Sixth report of session, 20 January 2023 3 Question on surgical mesh implants. Parallel Parliament, 14 December 2022 4 Letter to Health Select Committee December 2022. Sling the Mesh, December 2022 5 Government response to the independent inquiry report into the issues raised by former surgeon Ian Paterson. Department of Health and Social Care, 16 December 2021
  3. Content Article
    Key findingsPatients experienced long delays from time of arrival at hospital to time of surgery, including those with sepsis suspected at arrival in hospital (median 15.6 hours to theatre)Many patients (77.7%) with suspected sepsis on arrival did not receive antibiotics within an hour of arrival in hospitalOne in five high-risk patients did not receive postoperative care in a critical care unit.Frailty doubled the risk of mortality of patients aged 65 and over (13.0% vs 5.9%), but review by a member of the elderly care team was associated with a significant reduction in mortality (5.9% vs 9.5% amongst non-frail patients, and 13.0% vs 22.3% amongst frail patients). However, this is not routine practice in many hospitals.
  4. Content Article
    The report contains a number of findings related to: patterns of care at diagnosis staging and treatment planning waiting times along the care pathway curative surgery non-curative treatments. It also includes findings relating to the impact of the Covid-19 pandemic, including: In April 2020, the number of patients diagnosed with OG cancer was 43.6% of the 2019/20 monthly average, falling from 837 to 365 cases per month. The numbers diagnosed soon returned to normal levels, and in the period from June 2020 to March 2021, the number of monthly cases was 97.8% of 2019/20 levels. The percentage of patients diagnosed with stage 4 disease (advanced cancer) increased from 41.6% in 2019/20 to 44.9% in 2020/21. The report also contains recommendations for healthcare professionals, among which is including a call to review patients diagnosed after emergency admission and undertake root cause analysis to identify opportunities to reduce rates of emergency diagnosis.
  5. News Article
    German public research funder Deutsche Forschungsgemeinschaft (DFG) is conducting an audit of the clinical trials it has supported in the past. The audit was announced in response to a request from TranspariMED asking DFG for a list of all its trials completed between 2009 and 2017, to which DFG replied that it currently has no such comprehensive dataset. DFG stated that it is "currently preparing an evaluation of its clinical trials programme. In the framework of this evaluation the data you requested will be collected and analysed, as the outcomes of trials supported by DFG is of high interest including for DFG itself." TranspariMED, an organisation which aims to end evidence distortion in medicine, sees this development as a good opportunity for DFG to check whether and when clinical trials were registered and their results made public. Previous research has shown that nearly a third of German academic trials never make their results public. This not only wastes public money, but also harms patients because it leaves gaps in the evidence base on the efficacy and safety of drugs, medical devices, and non-drug treatments. Due to gaps in German law, there is still no legal obligation to make the results of many German clinical trials public. Read full story Source: TranspariMed, 20 December 2022
  6. Content Article
    Key messages Fall-related fractures can happen on any ward There is only one chance to get it right High quality multi-factorial risk assessment (MFRA) is necessary to ensure important fall risk factors are addressed Accurate post-fall checks support effective care All inpatients should have access to flat lifting equipment to move patients from the floor Inpatients who sustain a femoral fracture should have immediate access to analgesia Improvement activities should focus on fall prevention and post-fall management processes
  7. Content Article
    The report found that the datasets most likely to be identified as influencing change are those which review maternal and neonatal mortality, namely those produced by MBRRACE-UK and HSIB reports. Other key findings include: Recommendations were commonly identified as the most useful thing within reports, particularly by clinical staff Resource and time constraints for quality improvements were commonly cited as barriers, but More than 85% of respondents felt that at least one dataset was influencing quality improvement. The report goes on to make a number of recommendations, including a call for central bodies to develop a single website that signposts to all national maternity reports and datasets, and contains up-to-date guidance on all mandatory reporting requirements.
  8. Content Article
    This report highlights some key findings. Clinical services 100% of direct medical services were conducting the Clinical Standards Scorecards to ensure the safety of their service provision. However, use of the monthly and quarterly checklists was not as high or as regular. Direct service delivery in a majority of countries audited (5 out of 7) were fully compliant with the Clinical Standards. The average patient satisfaction score was 88%, outlining that in general, the 105 patients surveyed were satisfied with all aspects of service provision within our direct medical services. The report also makes recommendations for improvement related to: Infection prevention and control Morbidity and mortality reviews Clinical referrals Medical standard treatment compliance Clinical triage Infrastructure Human resources for health Pharmacy services Overall compliance to pharmacy standards varies significantly across countries, ranging from 57 to 100%. Compliance with waste management and Medical Incident Reporting (MIR) is generally high (above 80%) across all seven countries. Countries that were able to attend GMT Pharmacy Reference Group meetings on a regular basis had higher compliance scores. The report also makes recommendations for improvement related to: Sourcing medications In-country staff engagement Stock management Medication storage Ensuring pharmacy support at a local level
  9. Event
    The National Comparative Audit of Blood Transfusion is the largest programme of clinical audits of blood transfusion in the world and is funded by NHS Blood and Transplant. It began in 2002 and audits the administration of blood and blood components as well as assessing appropriate use of blood in various clinical settings. It is concluding its work on three National Comparative Audits: 2018 audit of the use of fresh frozen plasma, cryoprecipitate and transfusions for bleeding in neonates and other children 2019 Re-audit of the medical use of red cells 2021 audit of NICE Quality Standard 138 This webinar includes a 40 minute presentation by experts from NCA and SHOT teams. Register
  10. Event
    This one day masterclass, Mr Perbinder Grewal, General & Vascular Surgeon and Human Factors Trainer, will focus on teams working effectively and productively through improving the culture within healthcare organisations. There will be a focus on how safety and culture is perceived by healthcare staff and how culture relates to QI and audit. The outcome of the day is to not only improve safety culture and patient safety but also staff experience and staff engagement. Key learning objectives: Define culture within healthcare. Understand safety culture. Explore culture of quality improvement and audits. Improve civility within teams. Learn how to lead cultural change. All Medical and Non-medical Staff should attend. This masterclass is aimed at Clinical Staff, Team Managers, Senior Management. Register hub members receive 20% discount. Email: info@pslhub.org for discount code.
  11. Content Article
    The findings include: 71% of patients were checked for injury before being moved (up from 69% in 2019) Flat lifting equipment was used for 26% of patients (up from 22% in 2019), and 62% of patients were assessed by a medic within 30 minutes (up from 52% in 2019). The risk factor which was most often assessed was continence, with 74% patients undergoing this component of the MFRA (multi-factorial fall risk assessment). Lying/standing blood pressure was the least often assessed, with 35% getting this assessment. The report makes a number of recommendations, including a call to administer analgesia as soon as a provisional diagnosis of inpatient femoral fracture (IFF) is made, aiming for within 30 minutes of the fall.
  12. Content Article
    1 Medication delays: A huge risk for inpatients with Parkinson’s In this blog, Laura Cockram, Head of Policy and Campaigning at Parkinson's UK talks about the serious health implications of medication delays for people living with Parkinson's disease. She also offers recommendations for how hospitals can reduce the risk of harm. 2 Improving safety for diabetic inpatients: 4 key steps In this short film, National Specialty Advisor for Diabetes, Partha Kar shares 4 steps for improving the safety of diabetic inpatients. 3 Neonatal herpes: Why healthcare staff with cold sores should not be working with new babies Chief Executive and Founder of the Kit Tarka Foundation, draws on her own devastating experience of losing her son to illustrate why healthcare staff with cold sores must stay away from new babies. Sarah highlights the need for greater awareness and a widespread review of policy in order to prevent future deaths. 4 Measuring standards of care, not negative outcomes In this interview, Gavin Portier, Head of Nursing Quality, explains how his approach to auditing has moved beyond measuring negative outcomes, instead focusing on standards of care. Gavin shares related resources and some of their early results. 5 Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital Chase Farm Hospital now has 24-hour support for staff affected by adverse events. The model, developed by Theatre Nurse Carole Menashy, is known as the 365 second victim support model and sets out a framework to provide support at various levels from trained peers through to professional help. In this series of blogs, Carole explains how and why she set up the support service. 6 NHS Mid and South Essex's 'We're Listening' leaflet Danielle, Critical Care Outreach Nurse, share's her 'We're Listening' leaflet as part of the trust's Call for Concern service. This service has been developed so that patients, friends and family can alert the Critical Care Outreach team if they have concerns that need listening to and gives a telephone number to call and outlines the next steps. 7 Reducing intubation errors: A simple, accessible checklist to improve safety and support staff Sam Goodhand, a registrar specialising in anaesthetics and intensive care medicine, explains why he designed and printed simple checklist cards to help reduce life-threatening complications occurring during adult and paediatric intubation procedures. He shares details of how to order the cards for your area. #Share4safety Have you set up an initiative or made changes locally to improve safety? What were the challenges and successes? Are there any tools you've developed that may be useful to share with others? Why not get in touch with us at content@pslhub.org to tell us more and share your insights. Perhaps you'll be in our next Top Picks! Patient Safety Management Network Some of our members have recently come together to set up a collaborative network for people working in patient safety roles to support one another and share ideas. They currently run weekly drop-in sessions. If you'd like to join the network, simply sign up to the hub (for free) and tick the box for the Patient Safety Management Network. Make sure you fill out the 'about me' section to highlight how your role is relevant to the group. Stephanie O'Donohue, Content and Engagement Manager