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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    The UK nursing regulator’s new interim chief executive has stepped down just four days into the job after facing widespread staff backlash over her links to a high-profile race discrimination case. Multiple staff working at the Nursing and Midwifery Council (NMC) raised concerns to its directors over the appointment of interim CEO Dawn Broderick, who was head of HR at another trust when it was found to have discriminated against a Black employee. The Independent can now reveal Ms Broderick resigned from the NMC on Monday evening. It is the latest in a succession of controversies to hit the nursing regulator, following reports uncovered by The Independent last year. These include allegations from whistleblowers that racism within the NMC was allowing complaints against nurses to go unchecked. Staff have come forward to The Independent, warning they do not have confidence the NMC’s board will take the issue of racism seriously. Read full story Source: The Independent, 2 July 2024
  2. Content Article
    High volumes of patients are transferred every day between health and care settings. Whilst efforts have have been made over several years to improve this process through the implementation of standards and the sharing of digital information, there is more to be done. Whole system improvements are required and significant further progress can be made to improve the quality and consistency of data shared between organisations. The Professional Standards Record Body (PRSB) has published a number of standards that support the transfer of care of patients between settings.  This toolkit concentrates on the PRSB eDischarge Summary Standard, which specifies the data to be shared between secondary and primary care to support the discharge of a patient from hospitals across the UK. This toolkit does not propose a one-size-fits-all approach and recognises that health and care services are organised in different ways across the UK.
  3. News Article
    The agonising pains came midway through Dr Rageshri Dhairyawan’s third cycle of IVF, ten years ago. “I felt as if a heavy metal shovel was scraping away at the lining of my abdomen,” she recalls. “It was like nothing I’d ever felt before,” she says. Her fear was ovarian torsion — “when the ovaries become so big from all the follicle stimulation that they twist on their stalk, which is excruciating and needs to be repaired surgically because the ovary becomes starved of oxygen.” Her husband rushed her to A&E where she was given morphine, then admitted to a gynaecology ward. As a scan revealed no ovarian torsion, “It was thought the hormones had flared up my endometriosis.” Dhairyawan was in so much pain she couldn’t move, and yet she recalls being treated as though she was an attention-seeker “trying to get strong opioids through dishonest means” and “as a nuisance for pressing my buzzer”. It was as if, she says, “I didn’t have something they thought was very serious so why was I still there? I just remember not wanting to feel like more of a nuisance because I knew what being a nuisance on a ward can look like — I’d been a doctor for ten years.” Dhairyawan’s husband demanded pain relief for her. She left hospital shaken. “It massively changed me,” she says. “The experience of not being listened to as a patient, not being taken seriously — it really shocked me. Because I thought, I’m a senior doctor, I know exactly how the NHS works, I know my medical condition, I now what to ask for. And I still can’t speak up and advocate for myself.” Read full story (paywalled) Source: The Times, 2 July 2024
  4. News Article
    NHS trusts are signing up to deliver efficiency savings of up to 9% of costs, HSJ has found. The Queen Elizabeth Hospital King’s Lynn has a cost improvement programme of nearly £30m in 2024-25, equivalent to 9% of spending, which is three times higher than the amount it delivered last year. Trusts and commissioners were last month issued with new financial targets as NHS England attempted to bring down a £3bn forecast deficit for local organisations. A spokeswoman told HSJ the trust had already identified three-quarters of the £30m, and said “we believe that there are further efficiencies in our system, which would see us go further than the 3.1% achieved last year.” She added: “All cost-saving initiatives go through a robust process to make sure that they will not impact patient safety or clinical care provided by the trust.” Read full story (paywalled) Source: HSJ, 1 July 2024
  5. Content Article
    The Independent Healthcare Providers Network (IHPN) have launched a toolkit to support independent healthcare providers to further improve multi-disciplinary team (MDT) working in the sector.  MDT working is an established practice in many areas of healthcare, including in the independent sector, and for patients with complex care needs such as cancer, MDTs are viewed as the gold standard for care. 
  6. Content Article
    East Lancashire Hospitals NHS Foundation Trust share their guide on human factors. It describes what human factors is and why it is so important alongside example case studies of how human factors is being used within the Trust.
  7. News Article
    Doctors are warning the UK medical regulator that wider use of physician associates in the NHS may risk patient safety and lead to greater inequalities in care in deprived areas that struggle to recruit GPs. The government’s plan to recruit 10,000 physician associates – healthcare professionals supervised by doctors – has angered many clinicians who consider the roles ill-defined and a potential threat to patient safety. The General Medical Council (GMC) is to regulate physician and anaesthesia associates, who also work under doctors’ supervision, from December. The doctors’ union, the British Medical Association, last week announced it was seeking a judicial review of the GMC over the “dangerous blurring of lines” between doctors and medical associate professions. It argues physician and anaesthesia associates need regulating, but not by the GMC. Other professional membership organisations want clarification of associates’ roles. The Royal College of General Practitioners (RCGP) told the GMC that regulation is a “significant step forward”, but the scope of practice needs to be urgently developed. Read full story The Guardian, 30 June 2024
  8. News Article
    The latest release of data from the Royal College of Nursing's Last Shift Survey shows the urgent need for investment in the nursing workforce and safety-critical nurse-to-patient ratios enshrined in law. New analysis finds more than 11,000 members reveals just a third of shifts had enough registered nurses. Chronic staff shortages mean individual nurses are often caring for 10, 12, 15 or more patients at a time. The RCN are now calling for safety-critical limits on the maximum number of patients a single nurse can be responsible for. Our survey found that 1 in 3 hospital shifts were missing at least a quarter of the registered nurses they needed. In A&E settings, significant numbers of nurses reported having more than 51 patients to care for. Across all settings, 80% of respondents said there aren't sufficient nurses to meet the needs of patients safely. RCN Acting General Secretary and Chief Executive Professor Nicola Ranger said: “Without safety-critical limits on the maximum number of patients they can care for, nurses are being made responsible for dozens at a time, often with complex needs. It is dangerous to patients and demoralising for nursing staff. “When patients can’t access safe care in the community, conditions worsen, and they end up in hospital where workforce shortages are just as severe. This vicious cycle fails staff and patients – it can’t go on. “We desperately need urgent investment in the nursing workforce but also to see safety-critical nurse-to-patient ratios enshrined in law. That is how we improve care and stop patients coming to harm.” Read full story Source: RCN, 1 July 2024
  9. Content Article
    The Patient Safety Movement Foundation offers a unique educational opportunity for healthcare professionals around the world to expand their knowledge in the theory and practice of patient safety. Building on the World Health Organization Global Patient Safety Action Plan, the fellowship aims to develop future leaders particularly from lower middle and middle income countries. The programme combines a year-long curriculum developed by patient safety experts in a variety of areas, taught via monthly live virtual classroom sessions. Fellows complete monthly readings on specific topics, actively participate in discussions on the interpretation of theory and methods, and its implication to practice. Fellows submit monthly reflections on their learning as well as a longer reflection at the end of the fellowship. Applied learning is achieved by completing a hands-on improvement project that explores and advances issues of patient safety in each fellow’s respective professional environment. Fellows are encouraged to publish the outcome of their project and present at conferences. Fellows are driven by a deep passion for patient safety, often sparked by first-hand encounters with patient harm events, and a desire to improve care outcomes in their home communities and workplace settings. They become part of a global social movement for patient and healthcare worker safety. Information on how to apply can be found in the link below.
  10. News Article
    Hackers behind a London hospital attack recently published records that include personal information about pregnant women, newborns, cancer patients, people suffering from schizophrenia and thousands of others across the UK and Ireland, revealing the breach was far more widespread than authorities have previously indicated. An analysis of the data trove by Bloomberg News found that it contains tens of thousands of medical records on patients from more than 400 public and private hospitals and clinics. Among the records are some 40,000 highly sensitive documents sent by doctors requesting biopsies and blood tests for individual patients in all regions of the UK and some hospitals in Ireland. A breach of the kind faced by Synnovis was inevitable, according to Saif Abed, a former NHS doctor and expert in cybersecurity and public health. “The NHS has some of best patient safety and cybersecurity standards in the world,” Abed said. “They are just immensely poorly enforced.” Abed said that there was a lack of mandatory cybersecurity audits on any contractors providing services to the NHS, which meant those contractors could have substandard cybersecurity practices that could in turn leave the NHS vulnerable. Read full story Source: Bloomberg UK, 26 June 2024
  11. Content Article
    Read the latest case studies from the National Guardian’s Office.
  12. Content Article
    In the dynamic landscape of healthcare, the unexpected deterioration of a hospital patient presents formidable challenges for medical professionals and families alike. It is during these critical moments that the concept of patient rescue becomes profoundly significant. Families, empowered with knowledge and effective communication strategies, play a pivotal role alongside healthcare providers in advocating for their loved ones and contributing to the success of rescue efforts. Watch this video from the World Patients Alliance to enhance your skills and confidence in advocating for patients' needs.
  13. Event
    The Welsh Government, in partnership with the Restraint Reduction Network and Improvement Cymru, is pleased to announce this lunchtime webinar launching a brand-new coproduced animation and additional resources to support our work to reduce restrictive practices in Wales. In this webinar, co-chaired by Joe Powell, CEO of All Wales People First and Zara Newman, Welsh Government Head of Safeguarding and Advocacy, you will learn more about restrictive practices, the Welsh Government’s Reducing Restrictive Practices Framework and the resources available to support practitioners across health, care and educational settings. The resources, including the new animation, have been developed by the Welsh Government to raise awareness of restrictive practices and their lawful use in care and educational settings. There will be opportunity to ask questions on the day. The webinar is open to all. Please note that this webinar will also be translated into Welsh in real time. Register
  14. Event
    The RRN is currently developing version two of the RRN Training Standards. Over several months they have been hosting a number of events to hear from colleagues across sectors and nations to help inform the development of version 2 of the Standards. The next webinar will provide an update on progress to version 2 of the RRN Training Standards. Hosted by RRN Trustee Salli Midgley and RRN Training Standards authors Sarah Leitch and Dave Atkinson, the webinar will provide an update on progress and provide opportunity for discussion around some key issues. Colleagues from the health, social care and education sectors, and from across the UK and Ireland, are welcome. We warmly welcome people with lived experience. The Restraint Reduction Network is a movement of people who want to eliminate the use of unnecessary restrictive practices, protect human rights and make a positive difference in people's lives. You can join the movement for free today at: https://restraintreductionnetwork.org/become-a-member/ Register
  15. Content Article
    Clive Flashman, Patient Safety Learning's Chief Digital Officer, presented at a Health Tech Alliance meeting to innovators on how to engage with patients to improve the safety of digital health innovation. Clive addressed the challenges in patient engagement such as accessibility, interoperability, safety standards and privacy and data use. The presentation slides from the meeting can be downloaded from the attachment below.
  16. News Article
    Many doctors from overseas are left feeling lost, anxious and not ready to care for patients after joining the NHS because they are not properly looked after, research has found. Many international medical graduates (IMGs) feel the NHS does not help them prepare for life as a doctor in the UK and the practicalities of moving to a new country, according to a survey. Almost six in 10 (58%) of those questioned thought their induction was inadequate, and almost half (48%) felt anxious about starting to perform clinical duties in the UK. The Medical Protection Society (MPS), which surveyed 737 IMGs working in England, said the results showed that too many foreign-trained doctors were “still being let down” professionally and personally by the NHS. One doctor said: “I was very anxious and worried as working clinically without induction and [a] very brief period of shadowing … I was just lost.” Another said: “I asked several times about induction, to be told that I will just learn on the job and ‘it will be fine’.” Read full story Source: The Guardian, 28 June 2024
  17. News Article
    The NHS Race and Health Observatory has raised fundamental concerns about racism towards maternity patients after several cases have come to light in recent months, including midwives branding patients as “Asian princesses”. The watchdog’s intervention follows regulators identifying patterns of racist and discriminatory behaviour at the maternity departments of two large hospital trusts and a smaller general hospital in the last six months. The observatory’s CEO Habib Naqvi told HSJ he was “deeply concerned” by the seriousness of the issues raised. He added that “discriminatory behaviours and ways of working… [can] lead to hostile and unsupportive learning environments… impact patient care and safety, and also seriously undermine the NHS’s goal of attracting and retaining its workforce”. Examples given included the term “Asian princess” being used by midwives in reference to brown-skinned women requesting pain relief during labour. The students also described a “disregard” from some midwives towards black and brown-skinned women, particularly where English was not their first language. It was also reported when Asian women verbalised their pain during labour, some midwives responded with “Oh, they are all like this”, while additional derogatory comments were made towards asylum seekers, that “they are playing the system”, the NHSE team’s report said. Read full story (paywalled) Source: HSJ, 28 June 2024
  18. News Article
    An NHS England document has confirmed that that it wants to ‘optimise’ GP referrals to secondary care via an enhanced model of advice and guidance. GP leaders recently raised concerns that NHS England had encouraged Integrated Care Boards (ICBs) to adopt the ‘advice and refer’ model, effectively replacing traditional GP referrals and adding barriers for patients in accessing secondary care. At the time, NHS England did not address concerns about this specific model, but Pulse has now seen a ‘framework’ document which encouraged local commissioners to ‘strengthen’ specialist advice services in order to ‘optimise’ referrals. The guidance suggested the use of the ‘advice and refer’ model, which means all referrals or advice requests from GPs ‘come in through one route’ and directly bookable appointments are ‘discouraged or removed’. Under this service, all referrals are then ‘triaged’, allowing hospitals to reject referrals and send them back to GPs with advice. This mechanism removes the option for GPs to send standard referrals, whereas the usual model of advice and guidance (A&G) allows GPs to seek advice if they wish, but maintains the direct referral route. NHS England emphasised its commitment to empowering regions to ‘develop diverse models’ of specialist advice in line with their local needs. Read full story Source: Pulse, 26 June 2024
  19. Content Article
    The new PIER approach will enable the effective management of acute physical deterioration in health and care and will apply to all conditions, clinical settings and specialities. The new PIER approach views deterioration as a whole pathway which is supported by systems rather than only advocating a single strategy for identification. Acute physical deterioration is the rapid worsening of a patient’s condition. It can be identified from changes in physiology, such as respiratory rate, blood pressure or consciousness, or more subtle signs, such as not eating and a patient or their family’s concerns and observations around wellness, mental status or behaviour. Deterioration can occur in any health and care setting and is the common pathway in all emergency admissions, prolonged illnesses and deaths.
  20. News Article
    Kansas is the latest US state to file a lawsuit against Pfizer, accusing the pharmaceutical giant of misleading the public about the safety and effectiveness of its Covid-19 vaccine. Kansas Attorney General Kris Kobach claims that Pfizer knew about the risks associated with its vaccine, “including myocarditis and pericarditis, failed pregnancies, and deaths” but failed to disclose this information to the public. The 179-page lawsuit also alleges that Pfizer made ‘false and misleading’ statements regarding the vaccine's ability to prevent viral transmission, its waning effectiveness and its ability to protect against new variants of the virus. “To keep the public from learning the truth, Pfizer worked to censor speech on social media that questioned Pfizer’s claims about its Covid-19 vaccine,” alleges the lawsuit. Read full story Source: Maryanne Demasi, 23 June 2024
  21. Content Article
    On the 22 January 2024 Assistant Coroner Sarah Bourke began an investigation into the death of Anoush Summers who died aged 77, on the 14 January 2024 at Homerton University Hospital.   The deceased was a frail lady who was prone to falls. She lived at home, alone, with carers who visited her twice a day. She had a wrist alarm. The wrist alarm was reported as broken and not working on the 6 January 2024, but it was not repaired or replaced. Sometime after 4.45pm on 11 January 2024 the deceased fell at home. She was found the next day by a carer, wearing her wrist alarm and taken to hospital where she died on 14 January 2024 of hypothermia. The absence of a working wrist alarm prevented her from being found sooner that she was and probably contributed to her death.
  22. News Article
    NHS England has warned trusts corridor care “must not be considered the norm”, adding that the failings exposed by a recent undercover documentary were “not acceptable”. In a letter to boards after a Dispatches documentary filmed at Royal Shrewsbury Hospital aired on Monday, NHSE’s chief operating officer, chief nursing officer, national medical director and director of urgent and emergency care warned trusts they must ensure basic standards of care. The note, seen by HSJ, described footage filmed at RSH’s emergency department as “stark”, adding that it highlighted the service some patients receive is “not acceptable”. The documentary captured many instances of patients being treated in corridors, and the letter said corridor care or that delivered outside a normal cubicle environment “must not be considered the norm”. NHSE added: “It should only be in periods of escalation and with board-level oversight at trust and system level… where it is deemed a necessity… it must be provided in the safest and most effective manner possible, for the shortest period of time… with patient dignity and respect being maintained throughout.” Read full story (paywalled) Source: HSJ, 27 June 2024 Related reading on the hub: A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift
  23. News Article
    An assistant coroner has warned an east London council more people may die if it does not take action, after a "frail lady who was prone to falls" died of hypothermia at her home. Anoush Summers, 77, died in hospital in January after a fall days earlier. In a prevention of future deaths report, external, assistant coroner Edwin Buckett said Ms Summers' inquest concluded "the absence of a working wrist alarm prevented her from being found sooner than she was and probably contributed to her death". Ms Summers lived alone but received help from two carers from Supreme Care Services, and she was visited twice a day. After falling at home on 11 January, she was found the next day at 09:00 GMT wearing her wrist alarm and was taken to hospital. She died of hypothermia at Homerton University Hospital on 14 January. The assistant coroner said among issues he identified in her case "giving rise to concern" were: Her wrist alarm had been reported as broken and not working on 6 January, but "this was not replaced or repaired by the company engaged by the local authority", which meant Ms Summers could not call for help as "it did not work" None of the carers who attended her home after the wrist alarm broke on 6 January "ensured that steps were taken to replace the alarm" or reported the matter to the local authority The last carer to see her, who visited on 11 January, "was not aware that the wrist alarm did not work as she had not read the care notes", and "no clear instruction was given" about the extent to which carers should read these notes "None of the carers had been given any training, instruction or guidance on the testing of wrist alarms to ensure they worked properly when attending" There was not a "clear system identified between the company providing carers and the local authority as to the duties and responsibilities of each in the reporting of faults with wrist alarms" Read full story Source: BBC News, 26 June 2024
  24. Content Article
    This paper reviews the key perspectives on human error and analyses the core theories and methods developed and applied over the last 60 years. These theories and methods have sought to improve our understanding of what human error is, and how and why it occurs, to facilitate the prediction of errors and use these insights to support safer work and societal systems. Yet, while this area of Ergonomics and Human Factors (EHF) has been influential and long-standing, the benefits of the ‘human error approach’ to understanding accidents and optimising system performance have been questioned. This state of science review analyses the construct of human error within EHF. It then discusses the key conceptual difficulties the construct faces in an era of systems EHF. Finally, a way forward is proposed to prompt further discussion within the EHF community.
  25. Content Article
    Clinical safety is about keeping patients safe. It applies not only to us in the NHS, or social care organisations, but to you when building healthcare software. The law requires you to ensure your software is clinically safe, which means minimising the potential for harm to patients. This page on the NHS Digital website explains what you need to know about clinical safety when building healthcare software.
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