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Content Article
Can the NHS live with Covid? (Independent, 3 May 2022)
Patient Safety Learning posted an article in Exit strategies
Across the NHS, from routine care to emergency treatment, health leaders tell Rebecca Thomas in this special Independent report that pressure brought on by the pandemic has become unsustainable – with patients’ lives on the line as a result -
Content ArticleBoth the US Senate and the House of Representatives passed a bill to “improve the mental and behavioral health among health care providers” that President Biden signed on Friday. The Dr Lorna Breen Health Care Provider Protection Act is named after Lorna Breen, a New York City emergency medicine physician who died by suicide in April 2020, as Covid-19 raged across the city and the country. By all accounts a tireless worker, she was ultimately overwhelmed by what she experienced during those dark early days of the pandemic. Even before the coronavirus pandemic, health care institutions were struggling with maintaining the wellness of their workforces. Rates of burnout, depersonalisation, and emotional exhaustion were all significantly higher among healthcare workers than in the general population. Even more alarming, physicians and nurses complete acts of suicide at rates significantly higher than workers in other professions. The pandemic added fuel to this fire, as healthcare workers fought to provide care to legions of sick patients amid staffing and equipment shortages. Before the pandemic, approximately 40% of health care workers reported feeling burnt out. Now, between 60% and 75% of US healthcare workers report feeling emotionally drained and depressed. Clearly, something has to change. With the Breen bill, Congress hopes to halt this tragic wave of depression and burnout among health care workers by providing grants to hospitals and other health care organisations to “promote mental health and resiliency among health care providers.” Yet the solution the Breen bill proposes will not lead to meaningful change. Giving hospitals money to “promote wellness” will not magically heal healthcare workers. During the pandemic, hospitals across the country put up signs lauding their workers as heroes. Though hospital administrators may have given themselves pats on the back for such efforts, the signs meant little to those working without adequate personal protective equipment, or telling family members they could not visit dying loved ones, or wondering if they'd bring Covid home to their families and friends. The signs haven’t stopped scores of workers from leaving the healthcare field.
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Content ArticleIn 2010, the US Department of Health and Human Services Office of Inspector General (OIG) reported the first national incidence rate of patient harm events in hospitals—27% of hospitalised Medicare patients experienced harm in October 2008. During that month, hospital care associated with these events cost Medicare and patients an estimated $324 million in reimbursement, coinsurance, and deductible payments. Nearly half of these events were preventable. OIG conducted a new study to update the national incidence rate of patient harm events among hospitalised Medicare patients in October 2018. This work included calculating a new rate of preventable events and updating the cost of patient harm to the Medicare programme.
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Content ArticleLast week a think-tank report drew newspaper headlines with the claim that the NHS ranked second from bottom across "a series of major health outcomes" compared with other international systems. Does the NHS really perform so badly internationally, and is there a real problem with our health outcomes? Mark Dayan looks at the evidence.
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Content ArticleThe impact of COVID-19 on mortality can be broadly split into three categories: direct impacts; indirect impacts; and wider social and economic impacts. Indirect impacts represent excess deaths due to stresses on the health system or changes in the health-seeking behaviour of individuals. These are the focus of this bulletin from the COVID-19 Actuaries Response Group. At this stage of the pandemic, the mortality impacts are shifting from direct to indirect. Analysing emerging data can help to identify the magnitude of these impacts and the extent to which they are asymmetric across the population. If care pathways do not rapidly return to pre-pandemic levels, then the COVID-19 pandemic will affect the standard of healthcare, morbidity and mortality across the UK for years to come.
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Content ArticleThe formation of Integrated Care Systems (ICS) as part of the Government’s plan to integrate health and social care ought to be an opportunity for a once-in-a-generation improvement in the quality of social care provision. For too long the social care sector has been in crisis due to increasing demands on the system which have not been met with enough funding or a sensible organisational structure. Integration, if done properly, would alleviate many of the current problems and result in a better care experience for those who need care. However if integration is mishandled the Government will miss this unique opportunity and the crisis will continue, and indeed probably become more acute.
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Content ArticleMaternity services shouldn’t be waiting for whistle-blowers or inquiries to alert them to problems, says Dr Mark Ratnarajah, a practising paediatrician and managing director of C2-Ai. Instead systematic transdisciplinary reviews and real-time data should support a culture of shared learning, that helps ensure patient safety is everybody’s responsibility.
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Content ArticleAn investigation started on 9 October 2020 into the death of Matthew Alexander Caseby. Following his admission and subsequent absconsion from the Priory Hospital in Edgbaston, Matthew stepped in front of a train on the 8 September 2020 and was fatally injured. At the time, Matthew was suffering from disorder thinking and did not have the capacity to form any intention to end his life. Matthew absconded from Beech ward over a fence in the courtyard area and at the time of his absconsion Matthew was unattended. It was inappropriate for Matthew to be left unattended in the courtyard. There were concerns regarding Matthew absconding but the recording processes on Beech ward were inadequate which resulted in the communication to staff involved in Matthew's care being lacking. As a result of risks not being fully recorded, Matthew's risk assessment was not adequate as it was not based on all of the available information. Overall, the inadequate risk assessment for Matthew, the inadequate documentation records, the lack of a risk assessment for the courtyard area and the absence of a policy regarding observations levels in the courtyard means that the courtyard was not safe for Matthew to use unattended. His death was contributed to by neglect on the part of the treating hospital.
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Content ArticleTherese Coffey, the new health and social care secretary, sets out the government’s plans for the NHS and social care to deliver for patients, this winter and next. The government's plan for patients sets out the priorities for health and care, delivering across four key areas: ambulances backlogs care doctors and dentists. Read her Ministerial foreword below.
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Content ArticleThe UK health system is under unprecedented strain. The COVID-19 pandemic exacerbated these pressures, but it did not create them. The Academy of Medical Royal Colleges and its member organisations believe that as a country we are not facing up to the scale of the current challenges and we are not producing any coherent strategy to tackle the problems. Only when we confront these challenges will we be able to begin to fix the NHS. A combination of pressures means that the system is providing care and services which are sub-standard, threaten patient safety and fall below what should be expected in a country with the resources of the United Kingdom. If we do not act with urgency, we risk permanently normalising the unacceptable standards we now witness daily, to the detriment of us all.
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Content ArticleThe Institute for Safe Medication Practices Canada is a trusted partner in strengthening medication safety through learning, sharing, and acting to improve healthcare. A team of experts analyse reports of medication errors from across the country and provide resources, education, and consulting services to improve medication safety.
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Content ArticleSpecialised services typically care for small numbers of patients with rare or complex conditions. They are commonly overlooked in debates around the future of the NHS. This is despite costs growing by over 50% in eight years, and now exceeding £20bn per year. The spotlight is returning, with proposals from NHS England to change how these services are planned, with power and responsibility being devolved down to new Integrated Care Boards – sub-regional structures across England. This report sets out a series of recommendations which Policy Exchange believe should underpin these reforms, including refinement of the services into more logical groupings, an expanded role for patient and carer input into service design, and stronger ministerial and financial oversight to ensure the sustainability of service delivery for the longer term.
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Content ArticlePresentation from Professor Mark Brinell, Vice Chair and Global Healthcare Expert at KMPG, on lessons we can learn from integrated care systems across the globe.
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Content Article
Who killed patient safety? (5 May 2022)
Patient Safety Learning posted an article in Research, data and insight
The medical communities commitment to patient safety has withered over the past 10-15 years after the original call for action in 2000 with the release of the IOM report. What was once a call for action, safety in hospitals and oversight by government has been deprioritised, defunded, and devalued, leaving patients like the authors of this article wondering: What happened to patient safety? -
Content ArticleThis paper summarises how core NHSEI quality functions are expected to be delivered through Integrated Care Systems from April 2022. The functions covered are not exhaustive and the work is ongoing. This paper is a working draft which represents the current position, based on workshops and engagement with national policy teams, regional teams and systems.
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Content ArticleThe Ockenden review into the failings in maternity care at Shrewsbury and Telford Hospital NHS Trust in the UK makes for sobering reading. The review focuses predominantly on the period from 2000 to 2019 and estimates that there were significant or major concerns in the care of nine women and more than 200 babies who died while receiving care at the Trust. Many more women and babies suffered serious injuries. It was clear that the Shrewsbury and Telford Hospital NHS Trust did not investigate, learn, change, or listen to families when adverse events occurred. The conclusions of the Ockenden review make it clear that safe staffing levels, a well trained workforce, an ability to learn from incidents, and a willingness and ability to listen to families are all crucial for safe maternity care.
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Content ArticleThe UK’s new health secretary, Thérèse Coffey, has not taken on an easy job. Almost two-thirds of trainee GPs plan to work part-time just a year after they qualify, reporting that the job has become too intense to safely work more. A record 6.8 million people are waiting for hospital treatment in England, and 132,139 posts lie vacant across the NHS in England. Ian Sample hears from acute medicine consultant Dr Tim Cooksley about what’s happening within the NHS, and speaks to the Guardian’s health policy editor, Denis Campbell, about how the UK’s health and social care systems ended up in crisis and whether they can be fixed.
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Content ArticlePatients, families, and care providers affected by patient safety incidents expect there will be learning and improvement so that others will not suffer. For that, countries need mature data systems and a culture of safety that includes improving by learning from reporting hazards, harm, and near misses, as well as learning from situations and organisations where safe care is delivered consistently over time, which is in most cases. In this article, Ioana Popescu discusses patient safety in Canada. While systems are in place to support incident reporting, sharing, and learning from a variety of sources, in Canada truly national incident reporting is limited to medications, adverse drug reactions, and device failures. However, there are other pan-Canadian and grassroots efforts to advance reporting and learning from patient safety incidents that are complementary.
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Content ArticleThe Care Quality Commission provides answers to the following common myths.
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Content ArticleRather than being a static property of hospitals and other healthcare facilities, safety is dynamic and often on short time scales. In the past most healthcare delivery systems were loosely coupled—that is, activities and conditions in one part of the system had only limited effect on those elsewhere. Loose coupling allowed the system to buffer many conditions such as short term surges in demand. Modern management techniques and information systems have allowed facilities to reduce inefficiencies in operation. One side effect is the loss of buffers that previously accommodated demand surges. As a result, situations occur in which activities in one area of the hospital become critically dependent on seemingly insignificant events in seemingly distant areas. This tight coupling condition is called “going solid”. Rasmussen’s dynamic model of risk and safety can be used to formulate a model of patient safety dynamics that includes “going solid” and its consequences. Because the model addresses the dynamic aspects of safety, it is particularly suited to understanding current conditions in modern healthcare delivery and the way these conditions may lead to accidents.
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Content ArticleMinutes from the General Pharmaceutical Council meeting held on 14 July 2022. To be confirmed 8 September 2022.
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Content ArticleWith Liz Truss becoming the new Prime Minister today after winning the Tory leadership contest, what are the health and care commitments from the 2019 Conservative Party Manifesto that she inherits? Mark Dayan, Lucina Rolewicz and Jessica Morris explore the progress of the main health and care promises that were made. Which are on course to be delivered and which are not?
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Content ArticleFifteen years after a “moral moment” transformed patient safety here, new systems and a change in culture at John Hopkins Medicine have gone a long way toward eradicating errors.
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Content ArticleDuring the 20th century the locus of care shifted from large institutions into the community. However, this shift was not always accompanied by liberation from restrictive practices. In 2014 a UK Supreme Court ruling on the meaning of ‘deprivation of liberty’ resulted in large numbers of older and disabled people in care homes, supported living and family homes being re-categorized as ‘detained’. Placing this ruling in its social, historical and global context, this book presents a socio-legal analysis of social care detention in the post-carceral era. Drawing from disability rights law and the meanings of ‘home’ and ‘institution’ it proposes solutions to the Cheshire West ruling’s paradoxical implications.
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Content Article
HealthIT.Gov: SAFER guides (USA)
Patient Safety Learning posted an article in Health records and plans
The SAFER Guides consist of nine guides organiaed into three broad groups. These guides enable healthcare organisations to address electronic health record (EHR) safety in a variety of areas. Most organisations will want to start with the Foundational Guides, and proceed from there to address their areas of greatest interest or concern.
