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Content ArticleMajor new reform of the NHS will not work until Government addresses multiple chronic issues in the service, says the Public Accounts Committee (PAC) in a new report. The case has not been made for what improvements Integrated Care Systems (ICSs) will bring to patients, and by when. ICSs are the latest attempt to bring NHS and local government services together to join up services and focus on prevention. But the Committee says the reforms will founder if the major systemic problems in the NHS are not addressed by Government at a national level: the elective care backlog has breached seven million cases for the first time; major workforce issues have hamstrung both the NHS and social care; constantly increasing demand; a crumbling NHS estate; and limits on funding. These challenges require national leadership but there is a worrying lack of oversight in the new system, and crucial national projects like the NHS Workforce Plan and capital funding strategy are repeatedly delayed – what the Committee calls 'paralysis by analysis'. The cost of overdue maintenance has reached £9 billion - £4.5 billion classed as high or significant risk - and there are questions about who gets to keep proceeds of any assets sold under ICSs. Not enough is being done to focus on preventing ill-health, and not enough joint working between government departments to tackle the causes of ill-health. The failure to ensure adequate NHS funded dental care risks creating more acute dental health problems.
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News Article
USA: House Bill establishes Federal Agency dedicated to patient safety
Patient Safety Learning posted a news article in News
Nanette Barragán, US representative for California’s 44th Congressional District, has announced the introduction of new legislation intended to establish a National Patient Safety Board (NPSB) as a non-punitive, collaborative, independent agency to address safety in healthcare. This landmark legislation is a critical step to improve safety for patients and healthcare providers by coordinating existing efforts within a single independent agency solely focused on addressing safety in health care through data-driven solutions. Prior to the COVID-19 pandemic, medical error was the third leading cause of death in the United States, with conservative estimates of more than 250,000 patients dying annually from preventable medical harm and costs of more than $17 billion to the U.S. healthcare system. Recent data from the Centers for Medicare and Medicaid Services and Centers for Disease Control and Prevention indicate that patient safety worsened during the pandemic. The NPSB’s solutions would focus on problems like medication errors, wrong-site surgeries, hospital-acquired infections, errors in pathology labs, and issues in transition from acute to long-term care. By leveraging interdisciplinary teams of researchers and new technology, including automated systems with AI algorithms, the NPSB’s solutions would help relieve the burden of data collection at the frontline, while also detecting precursors to harm. A coalition of leaders in health care, technology, business, academia, and other industries has united to call for the establishment of an NPSB. “We have seen many valiant efforts to reduce the problem of preventable medical error, but most of these have relied on the frontline workforce to do the work or take extraordinary precautions,” said Karen Wolk Feinstein, PhD, president and CEO of the Pittsburgh Regional Health Initiative and spokesperson for the NPSB Advocacy Coalition. “The pandemic has now made things worse as weary, frustrated, and stressed nurses, doctors, and technicians leave clinical care, resulting in a cycle where harm becomes more prevalent. Many organizations have united to advance a national home for patient safety to promote substantive solutions, including those that deploy modern technologies to make safety as autonomous as possible.” Read full story Source: Business Wire, 8 December 2022 -
News Article
Our job is to keep people out of A&E
Patient Safety Learning posted a news article in News
As the pressures of winter and the Covid treatment backlog grow, the NHS is struggling. In Manchester, one organisation is pioneering a new way to care for people that tries to reduce the burden on the health service. It's the first call-out of the day for nurse Manju and pharmacist Kara in north Manchester. They are on their way to see Steven, who has been diagnosed with Parkinson's disease and had a fall the previous night. This might have led to a call-out for an ambulance crew and a visit to A&E. But instead the Manchester Local Care Organisation (LCO) stepped in. Once at Steven's house, Manju makes sure he hasn't been harmed by his fall, while Kara checks his medication. Manju notes that Steven's tablets could have contributed to his fall. Manju asks Steven how he copes going up and down the stairs. "I'm OK, just about," he says. But when he has a go at coming down the stairs, Manju spots he could use an extra grab rail and says she will sort one out. This intervention by the team has not only avoided Steven ending up in A&E, but also ensures he can continue to live independently in his own home. That's a key part of the LCO mission, according to Lana McEwan, one of the team leaders in north Manchester. "We would consider ourselves to be an admission-avoidance service, so we're trying to prevent ambulances being called in the first instance. "When an ambulance has been called, we're taking referrals directly from the ambulance service and responding within a one or two-hour response depending on need, and that's an alternative to A&E." Local neighbourhood teams are made up of nurses, social workers, pharmacists and doctors, all working together to keep people out of hospital. Read full story Source: BBC News, 9 December 2022 -
News ArticleLeaders of US ECRI and its affiliate, the Institute for Safe Medication Practices (ISMP), announce the launch of a joint Patient Safety Organization (PSO), an important step in making medication, medical devices, and healthcare practices safer for patients across all care settings, now during the COVID-19 pandemic, and into the future. Read full story Source: CISION PR Newswire
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News ArticleToday, four leading global organisations dedicated to fighting preventable deaths due to medical errors announced their partnership to co-convene the #uniteforsafecare programme on World Patient Safety Day (September 17, 2020). In June, the Patient Safety Movement Foundation announced the wide-ranging campaign to bring attention to system-wide improvements that will ensure better health worker and patient safety outcomes, called #uniteforsafecare. Now, the organisation will be joined by the American Society of Anesthesiologists (ASA), The Leapfrog Group, and International Society for Quality in Health Care (ISQua) in co-convening the slate of programming, which includes a virtual physical challenge to raise awareness of the issue; collaboration with the National Association for Healthcare Quality’s annual conference, NEXT; an in-person demonstration in Washington, D.C. and a free virtual event for the public and those who have experienced errors, harms, or death to themselves or loved ones. “As the first medical specialty to advocate for patient safety, and as physicians on the front lines treating COVID-19 patients, we know firsthand how critical ensuring health worker safety is,” said ASA President Mary Dale Peterson. “The issue is especially timely. From having the appropriate PPE to strategies for stress management and wellness – ensuring health worker safety is patient safety and improves outcomes. We are happy to participate in this effort to advance safety in health care.” Read press release
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News Article
Design of new breathing aid developed by Mercedes to be made freely available
Patient Safety Learning posted a news article in News
The designs of a new breathing aid developed by engineers at the Mercedes F1 team, University College London (UCL), and clinicians at UCL Hospital have been made freely available to support the global response to COVID-19. It's the latest development in Formula 1’s Project Pitlane effort to help fight coronavirus. The Continuous Positive Airway Pressure (CPAP) devices, which help coronavirus patients with lung infections to breathe more easily, were developed by engineers at the Mercedes team and University College London (UCL), and clinicians at UCL Hospital after a round-the-clock effort to reverse engineer a device that could be manufactured rapidly by the thousands. After patient evaluations at UCLH and across sister hospitals in the London area, the device received regulatory approval last week. An order for up to 10,000 has now been placed by the British National Health Service, and the Mercedes AMG High Performance Powertrains technology centre in Brixworth – the facility where the F1 team’s highly successful power units are developed and built – is now building 1,000 devices per day. Read full story Source: F1, 7 April 2020 -
News Article
"They don’t hide from the coronavirus, they confront it"
Patient Safety Learning posted a news article in News
As the world writhes in the grip of Covid-19, the epidemic has revealed something majestic and inspiring: millions of health care workers running to where they are needed, on duty, sometimes risking their own lives. In his article in the New York Times, Don Berwick says he has never before seen such an extensive, voluntary outpouring of medical help at such a global scale. Millions of health care workers are running to where they are needed, sometimes risking their lives. Intensive care doctors in Seattle connect with intensive care doctors in Wuhan to gather specific intelligence on what the Chinese have learned: details of diagnostic strategies, the physiology of the disease, approaches to managing lung failure, and more. City by city, hospitals mobilise creatively to get ready for the possible deluge: bring in retired staff members, train nurses and doctors in real time, share data on supplies around the region, set up special isolation units and scale up capacity by a factor of 100 or 1000. "We are witnessing professionalism in its highest form, skilled people putting the interests of those they serve above their own interests." Read full article Source: New York Times, 23 March 2020 -
News Article
New Chairman appointed for Patient Safety Movement Foundation
Patient Safety Learning posted a news article in News
Mike Ramsay has been appointed new Chairman of the Patient Safety Movement Foundation, taking over from Joe Kiani. The Patient Safety Movement's goal is to get to ZERO preventable deaths. In their latest newsletter, Mike discusses how he intends to build on the tremendous momentum gained so far. "We are not competing with any organization but strongly support entities with the patient safety goal and hope that we can all pull together and use all our resources to reach zero preventable deaths and zero harm. Zero is our target and we can get there!" Read Mike's Letter in the March Patient Safety Movement Foundation newsletter -
News Article
"Patients are not empowered to prevent their own harm", says Sir Liam Donaldson
Patient Safety Learning posted a news article in News
Today, Sir Liam Donaldson is chairing a patient safety meeting at the World Health Organization (WHO) 'A Global Consultation – A decade of Patient Safety 2020–2030' to formulate a Global Patient Safety Action Plan. His introductory address this morning focused on the task ahead – to maintain the World Health Assembly resolution momentum and patient safety as a global movement. "Patients are not empowered to prevent their own harm", Donaldson said, as he highlighted patient stories of unsafe care and the alarming parallels of patient and family experiences across the world. So where is the power? Donaldson went on to to highlight how the six current power blocks are not doing enough to improve safety and that we need to engage and motivate these power blocks to achieve change: Designing of health systems – we have not seen much evidence of systems being designed for safety. Health leaders are not using their power to lead for reduced harm. Educational institutions – these have to happen faster to train staff in. Research community – has patient safety research led to sustainable reduction in risk? Data and information – how has this improved patient safety? Industry – pharma doing very little on medication packaging and labelling; medical devices industry also could do more. -
Content Article
This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Jono talks to us about why he is passionate about making sure patient voices are heard and valued in healthcare investigations and quality improvement. He also highlights the current workforce crisis, the need to look after NHS staff to ensure they can deliver compassionate, high quality care and the importance of being transparent with the public about the problems the NHS is currently facing. -
Content ArticleThere are too many integrated care systems (ICSs) in some parts of the country, especially the South West and Midlands, writes Alastair McLellan and Dave West in this HSJ article. This means that effective integration will struggle due to limited resources, leadership capacity and ability to influence large providers. It is also a problem widely acknowledged at the centre and within the regions. The proposed structure for ICSs is overly complex, consisting of a partnership board with little statutory power, which is meant to give strategic direction to an executive board which in practice will be held accountable for all decisions, but which is also meant to give up as much power and money as possible to “place based” entities which remain ill defined and have no statutory standing.
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Content ArticleProvider collaboratives are partnerships that bring together two or more NHS trusts (public providers of NHS services including hospitals and mental health services) to work together at scale to benefit their populations. While providers have worked together for many years, the move to formalise this way of working is part of a fundamental shift in the way the health and care system is organised, moving from an emphasis on organisational autonomy and competition to collaboration and partnership working. This King's Fund explainer looks at provider collaboratives in England, the opportunities they provide and the unresolved questions to consider when thinking about their role in the changing health and care landscape.
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Content ArticleFrom the perspective of patient partners, the Ontario SPOR SUPPORT Unit Engaging Multi-stakeholders for Patient Oriented-research Wider Effects and Reach Awards have facilitated successful patient-partnered research projects, which, in turn, have led to an evolution in patient partnerships and engagement strategies. The 15 projects profiled in this special issue point to the beneficial impacts of patient-partnered research.
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Content ArticleAn increasing number of cancer patients are using the internet to better understand their disease and connect with others facing the same challenges. Online cancer communities have developed into resources that highlight new research and evolving treatments. Combined with increasing health literacy and social media, they have enabled some patients to become experts in their cancer. This article in the journal JCO Oncology Practice examines the role of expert patients (e-patients) in advancing cancer medicine, and looks at opportunities available to those who wish to become more involved in research advocacy. The authors found that e-patients play a greater role in their own care and in larger conversations regarding practice, research, and policy. They highlight that clinicians can engage e-patients as partners in cancer care to work together towards improving healthcare access and outcomes for people with cancer.
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Content ArticleNow that the national plan to tackle the elective backlog is public, thoughts will be turning to how to achieve the challenging task ahead. A week before the plan was published, the King's Fund held a roundtable, supported by Novartis, with local health care leaders to discuss just that. The overwhelming theme from this discussion was that effective communication within local systems will be essential to success. The national strategy has set out the ambition, but ultimately solutions will be implemented locally. Five relationships stood out as being vital. Local areas and their neighbours. Primary and secondary care. Leaders and their workforce. NHS and patients. Local systems and their data.
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Content Article
PRSB: Social Prescribing Standard V0.2
Patient Safety Learning posted an article in Social prescribing
For many people, improving their health and wellbeing requires a holistic approach and support by professionals who can help them focus on what matters to them to live well. Social prescribing supports people to understand their needs and connects them to local community (non-clinical) often voluntary services which can provide the help they need. -
Content ArticleWe need to make community-powered prevention a valued part of the system, writes Prof Donna Hall in this HSJ article. Mark Spencer is a GP who has completely reinvented his role. Tired of sitting in his surgery day after day prescribing medicines to the same people with the same conditions, he decided to get out into the communityand talk to them about what needed to change. The result is Healthier Fleetwood - a remarkable flowering of multiple community-led groups. The groups cover a wide range of issues from men’s mental health to obesity. But they all share one thing in common - they use the power of human connection and support to prevent illness in the first place rather than simply manage it. This is why there are groups dedicated simply to singing or crafts as a way of keeping people mentally and physically healthy, as well as those more directly focused on “conditions”. The results speak for themselves - reduced obesity, falling admissions to accident and emergency (pre-covid), and a doubling of GP numbers made possible by more sustainable finances. And, most importantly, dozens of stories of people’s lives transformed, even saved.
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Content ArticleThis long read by the Health Foundation examines the challenges of discharging people from hospital, and looks at 'discharge to assess' (D2A) an approach to reducing the incidence of delayed discharge. It outlines priorities for policymakers and the NHS and suggests next steps for managing hospital discharge.
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Content ArticleThe East of England share their race strategy.
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Content ArticlePlans to establish integrated care systems (ICSs) as statutory bodies in the health and care bill foreshadow further changes to the organisation of the NHS. Unlike previous reorganisations, the changes expected to occur in 2022 have developed from within the NHS rather than being imposed by the government. Not only this, but leaders in the NHS have also played a major part in shaping the nature of these changes in partnership with the centre. This paper from the NHS Confederation focuses on the changes needed to create the conditions in which ICSs can improve outcomes for patients and the public and outlines a series of simple rules to guide those leading the reform programme. The ideas put forward are intended to provide a basis for debate with healthcare leaders and others in England about next steps. The paper starts from the premise that a key role of leaders is to harness the intrinsic motivation of health and care staff and public health teams to perform to the best of their abilities. The distinctive contribution of ICSs is to work with partners in making use of all available assets and leading improvements in patient care and outcomes that require actions across the organisations and services that make up the health and care system. Staff must be fully engaged in this work as it is through their actions that patients and the public will experience improvements
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Content Article
WHO - Announcing World Patient Safety Day 2022 (4 March 2022)
Patient-Safety-Learning posted an article in WHO
The theme for World Patient Safety Day 2022 is Medication Safety. It will take place on 17 September 2022. Unsafe medication practices and medication errors are a leading cause of avoidable harm in healthcare across the world. Medication errors occur when weak medication systems, and human factors such as fatigue, poor environmental conditions or staff shortages, affect prescribing, transcribing, dispensing, administration and monitoring practices. This can result in severe patient harm, disability and even death. The ongoing Covid-19 pandemic has significantly exacerbated the risk of medication errors and associated medication-related harm. The theme builds on the ongoing WHO Global Patient Safety Challenge: Medication Without Harm. It also provides much-needed impetus to take urgent action for reducing medication-related harm through strengthening systems and practices of medication use. -
Content Article'Deep End’ general practices serve communities in the most socioeconomically disadvantaged areas. The analogy of the deep end of the swimming pool to describe how a one size fits all funding model for NHS GP practices regardless of area-based differences in patient needs leaves health professionals in high-deprivation places treading water to stay afloat. Lincolnshire’s East Coast is now amongst the most deprived communities in the UK. This in-depth article in BJGP Life reports on an event for local healthcare professionals and academic researchers hosted by First Coastal Primary Care Network (FCPCN) in November 2021, in Skegness, Lincolnshire. The aim of the event was to discuss the challenges that health professionals working within the FCPCN face with a focus on inequities and the experiences of the healthcare workforce.
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Content Article
In this blog, Clare Rayner, an occupational physician, describes how an international collaboration to help understand Long Covid was established by harnessing the power of technology and social media. This collective, between a group of UK doctors experiencing prolonged health problems after Covid-19 infection and a globally renowned rehabilitation clinic at Mount Sinai Hospital in New York, aims to help both patients and healthcare professionals by disseminating learning about Long Covid from both sides of the Atlantic. -
Content ArticleA report looking at how the government can lock in the lessons of the COVID-19 pandemic to build a more robust, sustainable and joined-up system of social care.
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Content Article
This is the first of a short series of blogs in which we take a look back at our work in five areas of patient safety during 2021. This blog explores how the hub has encouraged collaboration, connection and the sharing of patient safety solutions. Through our work, Patient Safety Learning seeks to harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. We believe patient safety is not just another priority; it is a core purpose of health and social care. Patient safety should not be negotiable.
