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Content Article
In October, the Healthcare Safety Investigation Branch will tweak its name, become independent from NHS England and the UK government, and gain new powers to strengthen investigations. With the announcement of the change in status, Health Secretary, Steven Barclay, reported it would be leading an investigation into inpatient mental health. This follows swiftly on the heels of the Strathdee rapid review into data on mental health inpatient settings, which itself was launched in response to well-documented failures in these settings. The aim of this new investigation into mental health is simple: to improve safety. In this blog, Karen West, Head of Transformation (Mental health) at Oxehealth, and Professor Dan Joyce from the University of Liverpool, discuss the importance of data in patient safety improvement and explain why inpatient mental health data is so difficult to collect and what can be done to improve this. -
Content ArticleThe report from the International Labour Organization describes the results of a special analysis of data from the Labour Force Surveys (LFS) of 56 countries which provided data about health and social care workers in sufficient detail to distinguish between different occupational groups within the workforce. The report covers analyses for 29 countries in Europe and 27 from other regions of the world. This analysis can help to highlight specific occupation groups and countries which are at heightened risk of decent work deficits and demographic imbalances.
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Content Article
I am passionate about women's health and have worked with campaigners, clinicians and patients for a number of years to look at the barriers that women face in receiving safe care and the challenges clinicians face in delivering it. We know the medical system has historically been based on the white, male patient which has led to huge gaps in knowledge and understanding around women's health. But we are not just playing catch up to address past racism and patriarchy that is embedded in the system, we are continuing to highlight and fight it where it still exists. On Saturday I attended the Women's Health Summit, organised by Five X More. It was a powerful event, designed to look at aspects of women's health throughout their life journey. Attended by mums, charity representatives, media, clinicians, patients, leaders and more, united by a desire to change things. I laughed, I talked and I cried. One of the final calls to action of the day was to find your skill, find your voice and do more. So, I start where I am most at home - in writing. -
Content ArticleThe Maternal, Newborn and Infant Clinical Outcome Review Programme, which is delivered by MBRRACE-UK, has published a report on UK Perinatal Deaths for Births from January to December 2021. Overall, it found that perinatal mortality rates increased across the UK in 2021, with 3.54 stillbirths per 1,000 total births and 1.65 neonatal deaths per 1,000 live births (3.33 and 1.53 respectively in 2020). However, there was a wide variation in stillbirth and neonatal mortality rates across organisations, though these rates increased in almost all gestational age groups. It was also found that inequalities in mortality rates by deprivation and ethnicity remain, but the most common causes of stillbirth and neonatal death are unchanged (for example, congenital anomalies continue to contribute to a significant proportion of perinatal deaths).
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Content ArticleCommunity hospitals play a very important role in supporting patients but, unlike with larger hospitals, little has been known until now about how they struggle with delayed discharges. Following a freedom of information request, the Nuffield Trust reveals the number of patients experiencing delays leaving community hospitals, and highlights the capacity challenges such hospitals face.
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Content ArticleThe Aviation Safety Reporting System (ASRS) is an important part of the continuing effort by the US government, industry and individuals to maintain and improve aviation safety. The ASRS collects voluntarily submitted aviation safety incident/situation reports from pilots, controllers and others. it analyses and responds to these incident reports to reduce the likelihood of aviation accidents. ASRS data are used to: identify deficiencies and discrepancies in the National Aviation System (NAS) so that these can be remedied by appropriate authorities. support policy formulation, planning for and improvements to the NAS. strengthen the foundation of aviation human factors safety research. This is particularly important since it is generally recognised that over two-thirds of all aviation accidents and incidents have their roots in human performance errors. The ASRS website outlines the purpose and aims of the system, provides details on how to submit reports and lists related research studies and resources.
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EventuntilDeveloping trust when it comes to the employment of AI-driven healthcare is a complex challenge, and one that’s easy to get wrong. Daniel Morris, Partner at Bevan Brittan, Mahesh Hariharan, Founder and CEO of Zupervise, and Surabhi Srivastava, Commercial VP of Qure.ai, will together explore the importance of trust in AI-driven healthcare, and how effective governance can help build trust between patients & providers. They will discuss topics such as: data provenance; algorithmic transparency; and the role of human oversight in ensuring patient safety and data security. Register
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Content ArticleThe number of under-50s worldwide being diagnosed with cancer has risen by nearly 80% in three decades, according to the largest study of its kind. Global cases of early onset cancer increased from 1.82 million in 1990 to 3.26 million in 2019, while cancer deaths of adults in their 40s, 30s or younger grew by 27%. More than a million under-50s a year are now dying of cancer, the research reveals. Experts are still in the early stages of understanding the reasons behind the rise in cases. The authors of the study, published in BMJ Oncology, say poor diets, alcohol and tobacco use, physical inactivity and obesity are likely to be among the factors. “Since 1990, the incidence and deaths of early onset cancers have substantially increased globally,” the report says. “Encouraging a healthy lifestyle, including a healthy diet, the restriction of tobacco and alcohol consumption and appropriate outdoor activity, could reduce the burden of early onset cancer.”
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Content ArticleHealthcare is where the "most exciting" opportunities for artificial intelligence (AI) lie, an influential MP has said, but is also an area where the technology's major risks are illustrated. Greg Clark, chairman of the Commons Science, Innovation and Technology Committee (SITC), said the wider adoption of AI in healthcare would have a "positive impact", but urged policy makers to "consider the risks to safety". He said: "If we're to gain all the advantages, we have to anticipate the risks and put in place measures to safeguard against that." An interim report published by the Science, Innovation and Technology Committee sets out the Committee’s findings from its inquiry so far, and the twelve essential challenges that AI governance must meet if public safety and confidence in AI are to be secured.
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News ArticleMore than 120,000 people in England died last year while on the NHS waiting list for hospital treatment, figures obtained by Labour appear to show. That would be a record high number of such deaths, and is double the 60,000 patients who died in 2017/18. For example, the Royal Free hospital in London said it had had 3,615 such deaths, while there were 2,888 at the Morecambe Bay trust in Cumbria and 2,039 at Leeds teaching hospitals trust. Hospital bosses said the deaths highlighted the dangers of patients having to endure long waits for care and reflected a “decade of underinvestment” that had left the NHS with too few staff and beds. Healthwatch England, a patient advocacy group that scrutinises NHS performance, said the number of people dying while waiting for care was “a national tragedy”. Louise Ansari, the chief executive, said: “We know that delays to care have significant impacts on people’s lives, putting many in danger.” Read full story Source: The Guardian, 31 August 2023
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Content ArticleThe number of cyberattacks and information system breaches in healthcare has grown steadily, escalating from isolated incidents to widespread targeted and malicious attacks. In 2022, 707 data breeches occurred in the US, exposing more than 51.9 million patient records, according to data from the Department of Health and Human Services (DHHS). To help healthcare organisations address this growing patient safety concern, The Joint Commission has issued this Sentinel Event Alert that focuses on risks associated with cyberattacks and provides recommendations on how healthcare organizations can prepare to deliver safe patient care in the event of a cyberattack.
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News Article
Flu jab IT system to be ‘switched off’ weeks before vaccine programme starts
Patient-Safety-Learning posted a news article in News
All tech support for flu and covid vaccinations will be switched off on Thursday after NHS England decided against extending its contract with its supplier in favour of developing an in-house system, according to HSJ. NHSE last week told suppliers System C and Graphnet it would not extend the contract for the National Immunisation Management Service – just one week before the contract ends. NIMS, provided by the two British firms in partnership with NHS South Central and West Commissioning Support Unit, has been used for the last three years to manage the vaccination programme. Its functionalities include a single data store holding vaccination records for more than 60 million people, a call and recall service that can identify and contact groups of eligible individuals according to age and clinical priority, and reporting and analysing of vaccination activity in “near real time”. NHSE informed System C it would not extend the contract last Thursday – five working days before it was due to expire, according to a message from System C to customers, seen by HSJ. In its message, System C said: “This means that all functionality, including the NIMS application programming interface links to third party booking systems, all outgoing feeds and extracts, NIMS dashboards and the point of vaccination data capture application will stop working after 31 August.” There is currently “significant usage” of the system by GPs and trusts, which means NIMS users “may need to take action to deal with the retirement of the system” – the message stated. Read full story (paywalled) Source: HSJ, 30 August 2023 -
News Article
Global COVID-19 data gap grows as countries stop reporting to WHO
Patient Safety Learning posted a news article in News
Fewer than 20 countries worldwide still report COVID-19 hospitalisation and ICU data to the World Health Organization (WHO), leaving the UN health body blind to the impact and evolution of the virus in most of the world, agency leaders have said. The decline in data reporting is a major setback for the WHO’s efforts to track the pandemic. Without reliable data, the WHO cannot accurately assess the burden of disease, identify new variants, or target its resources where they are most needed. “We don’t have good visibility of the impact of COVID-19 around the world,” said Dr. Maria Van Kerkhove, who leads the WHO’s COVID-19 task force. “It is really important that surveillance continues, and this is on the shoulders of governments right now.” “While we are certainly not in the same situation that we were in a year ago or two years ago, SARS-Cov-2 circulates in all countries right now,” said Van Kerkhove. “It is still causing a large number of infections, hospitalisations, admissions to the ICU and deaths.” The current set of dominant COVID-19 variants can still cause the “full spectrum” of disease, from asymptomatic infections to severe disease and death, Kerkhove said. Read full story Source: Health Policy Watch, 25 August 2023 -
News Article
Norfolk and Suffolk NHS trust deaths report 'watered down to spare bosses'
Patient Safety Learning posted a news article in News
A critical report into how a mental health trust mismanaged its mortality figures was edited to remove criticism of its leadership, the BBC has found. In June, auditors Grant Thornton revealed how the Norfolk and Suffolk NHS Foundation Trust (NSFT) had lost track of patient deaths. But earlier drafts included language around governance failures that were missing in the final version. NSFT and Grant Thornton said the changes were due to fact-checking. A number of drafts of the report were produced, with the first dated 23 February this year. The first version described "poor governance" in the way deaths data was managed, with governance also being called "weak" and "inadequate". But many of these critical words were missing from the report released to the public, with "governance" also being replaced with "controls", according to leaked documents. After losing her son Tim in 2014, Caroline Aldridge has been highlighting what she and others claimed had been the trust's undercounting of deaths. "I think people need to know what was removed and what was changed, because I suspect that the first report is a lot nearer to the truth," she said. Ms Aldridge added: "It takes all responsibility from governance, removing the words 'inadequate', 'poor', 'weak' governance, removing significant pieces of information that's not factual accuracy. "We cannot have people watering it [the report] down when it's about deaths." Read full story Source: BBC News, 29 August 2023 -
Content ArticlePublicly available data from the Office for Health Improvement and Disparities (OHID) shows a persistently high number of excess deaths involving cardiovascular disease (CVD) in England since the beginning of the pandemic. This analysis of by the British Heart Foundation looks at this situation in more detail.
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News ArticleMore than 3,000 patients have died following incidents in the Irish health service since 2018, new data shows. New HSE data shows more than 480,000 incidents potentially causing harm were recorded across hospitals and community healthcare groups since 2018. These include falls, attacks on patients or staff, problems with medication, treating the wrong limb, or reactions to medical devices, among other issues. Last year’s total of 106,967 was the highest of five years recorded, up from 94,422 in 2018. While around half the incidents annually led to no injury, last year 0.65% or 556 led to a death. That stood at 0.59% or 557 deaths in 2018. A spokesperson for the Irish Nurses and Midwives Organisation (INMO) said the figures are very high, but not surprising. “Hospitals are not supposed to be dangerous places," she said. "No matter how highly skilled your staff are, patient safety issues and the risk of missed care incidents are inevitable in a situation where patients are lining corridors on trolleys and there aren’t enough staff to care for them." Read full story Source: Irish Examiner, 18 August 2023
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Content ArticleMany patients struggle to book a GP appointment in England. Once people have been successful in getting a booking to see their doctor, however, how long are they having to wait for their appointment? Charlotte Paddison looks at the latest data to reveal the answer – and argues that quick access to GP appointments is not the only factor to consider.
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Content ArticleIn January 2023, NHS England’s Delivery plan for recovering urgent and emergency services committed the health service to ease the growing pressure on hospitals by scaling up the use of ‘virtual wards’. Also known as ‘hospital at home’, virtual wards allow people to receive treatment and care where they live, rather than as a hospital inpatient, while still being in regular contact with health professionals. This article by The Health Foundation looks at how NHS staff and the UK public feel about the use of virtual wards, based on the results of a survey of 7,100 members of the public and 1,251 NHS staff members. The survey aimed to assess how supportive these groups are of virtual wards and what they think is important for making sure they work well.
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Content ArticleThis guidance for users of the new Learn from Patient Safety Events (LFPSE) service provides context and guidance on selection of appropriate categories when recording incidents. It focuses on which Event Type is appropriate for different circumstances, and how to select the most appropriate options for the Levels of Harm categorisation required within Patient Safety Incidents. It covers the following topics: Definitions – event types Definitions – harm grading When are harm grading fields mandatory? Recording guidance questions and answers
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Content ArticleThis report by the National Audit of Dementia (NAD) presents the results of the fifth round of audit data. For the first time, the audit has been undertaken prospectively, which will enable hospitals to take earlier action to improve patient care and experience. However, this has demonstrated that many hospitals still have no ready mechanism to identify people with dementia once admitted. One notable improvement is delirium screening (dementia is the biggest risk factor for developing delirium). Screening for delirium has improved from 58% in round 4 to 87% in the current audit. In addition, a high number of pain assessments are also being undertaken within 24 hours of admission (85%). Although encouraging, the report highlights that 61% of these assessments were based only on a question about pain—an approach that can be unreliable in patients with dementia. While this report acknowledges that our health services have experienced an extraordinarily difficult and challenging time, it does shine a light on a need for more training. It states that is encouraging that many staff have received Tier 1 dementia training (median 86%), but suggests that a much higher proportion of ward-based patient facing staff should have received Tier 2 dementia training (median 45%). It found that only 58% of hospitals are able to report the proportion of staff who have received training. As such, the report recommends that any member of staff involved in the direct care of people with dementia should have Tier 2 training, and this training should be recorded to provide assurance to the public and regulators.
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News ArticleVanderbilt University Medical Center is facing a federal civil rights investigation after turning the medical records of transgender patients over to Tennessee’s attorney general, hospital officials have confirmed. The U.S. Department of Health and Human Services’ investigation comes just weeks after two patients sued VUMC for releasing their records to Attorney General Jonathan Skrmetti late last year. “We have been contacted by and are working with the Office of Civil Rights,” spokesperson John Howser said in a statement late Thursday. “We have no further comment since this is an ongoing investigation.” VUMC has come under fire for waiting months before telling patients in June that their medical information was shared late last year, acting only after the existence of the requests emerged as evidence in another court case. The news sparked alarm for many families living in the ruby red state where GOP lawmakers have sought to ban gender-affirming care for transgender youth and limit LGBTQ rights. The patients suing over the release of their information say VUMC should have removed personally identifying information before turning over the records because the hospital was aware of Tennessee authorities’ hostile attitude toward the rights of transgender people. Many of the patients who had their private medical information shared with Skrmetti’s office are state workers, or their adult children or spouses; others are on TennCare, the state’s Medicaid plan. Some were not even patients at VUMC’s clinic that provides transgender care. “The more we learn about the breadth of the deeply personal information that VUMC disclosed, the more horrified we are,” said attorney Tricia Herzfeld, who is representing the patients. “Our clients are encouraged that the federal government is looking into what happened here.” Read full story Source: NBC News, 10 August 2023
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Content ArticleDelayed discharges, where a patient is medically fit to leave hospital but is not discharged, were a particular problem in England in the winter of 2022/23. In this article, Camille Oung from the Nuffield Trust highlights some possible solutions to help better prepare health and care services for discharge pressures next winter.
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News Article
Allergy emergencies double in recent years in England
Patient Safety Learning posted a news article in News
Dangerous allergic reactions are rising in England and now cause some 25,000 NHS hospital stays a year, according to data gathered by the NHS and analysed by the Medicines and Healthcare products Regulatory Agency. Health officials say the rate has more than doubled over 20 years, prompting them to issue advice reminding people how to recognise allergies and respond. For severe food-related allergic reactions, the rise in admissions is even greater. The figures suggest anaphylaxis is on the increase, though some of the rise could be attributed to the growth in population. Anaphylaxis can be fatal and develop suddenly at any age. People who know they are at risk should always carry two adrenaline pens which they, or someone else, can administer in an emergency. In addition, people at risk of an anaphylactic reaction should regularly check the contents of their adrenaline pens have not expired. They should see a pharmacist to get a new one if a pen is close to expiring. Read full story Source: BBC News, 28 July 2023 -
Content Article9.1 million people will be living with major illness by 2040, 2.5 million more than in 2019, according to this new report published by the Health Foundation. The analysis is part of a four-year project led by the Health Foundation’s Real Centre in partnership with the University of Liverpool, focusing on levels of ill health in the adult population in England up to 2040. It lays out the scale and impact of the growth in the number of people living with major illness as the population ages.
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Content Article
Safety thermometer tool (NEQOS)
Patient-Safety-Learning posted an article in Quality Improvement
The aim of the NHS Safety Thermometer is to provide a local improvement tool for measuring, monitoring and analysing patient harms and ‘harm free care’. Data is collected by Trusts on pressure ulcers, falls, urinary tract infections (UTI), and Venous Thromboembolism (VTE) assessments, prophylaxis and treatment. The North East Quality Observatory Service (NEQOS) Safety Thermometer Tool allows trusts to compare themselves against their peers (for improvement purposes) as well as to undertake internal comparisons across different service areas within the Trust. Produced quarterly, the tool uses National Safety Thermometer data published by NHS Digital and presents this by Trust across the North East & North Cumbria (NENC) area, providing comparisons between peers as well as with the national average, with breakdowns by service areas for detailed analysis.
