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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
    At a time when the potential of technological innovation to improve patient safety and patient outcomes is increasingly undeniable, tangible results are still a long way off. Our aim is to provide an opportunity for discussing the missing links that prevent the vision of breakthrough digital solutions from translating into genuine improvements in patient safety and outcomes. It will be held in the prestigious Colegio de Médicos of Madrid. This venue, with its amphitheatres charged with medical history, reflects the ambition we have for this conference: to be a forum that brings together the views of all the stakeholders involved in patient safety in order to achieve concrete improvements. Register
  2. Content Article
    The Parliamentary and Health Service Ombudsman's annual report and accounts 2023 to 2024 gives details of its performance over the past 12 months, including financial reports and statistical information about the complaints received.
  3. News Article
    Thousands of GP practices — and some other localised services — are without their IT systems today, due to global outages also affecting banking, media and aviation. All EMIS GP IT systems, which are used by more than half of the 8,000-odd GP practices in England, were down. It was leaving many practices unable to book appointments or consult with patients first thing on Friday morning. This will quickly lead to a backlog of appointments and likely pressure on other urgent care. Patient-facing digital services linked to EMIS also appeared to be down, such as records access via the NHS app. The National Pharmacy Association said some community pharmacy services were down — such as “accessing of prescriptions from GPs and medicine deliveries” were disrupted. It’s unclear if that is also caused by EMIS, or other systems. Read full story (paywalled) Source: HSJ, 19 July 2024
  4. Content Article
    Last year, before the publication of Labour's health mission, the Health Foundation set out five tests for political leadership on a whole-government approach to health inequalities. As Prime Minister Keir Starmer’s new government starts work, the Health Foundation looks back at those tests and asks: how far they have been met? And what further steps would the new government need to take to meet them? 
  5. News Article
    A fifth of the nursing and midwifery professionals who left the register in the last year did so within 10 years of joining, figures show. Nursing leaders described the statistic as “deeply alarming” and called on ministers to “grasp the nettle and make nursing an attractive career”. The latest Nursing and Midwifery Council (NMC) annual report on its register of nurses, midwives and nursing associates in the UK shows 27,168 staff left the profession between April 2023 and March 2024, a slight decrease on the previous 12 months. However, 20.3% of the total - or 5,508 - did so within the first 10 years. This is compared to 18.8% in 2020/2021 and “reflects a rise over the last three years”, according to the report. Professor Nicola Ranger, general secretary and chief executive of the Royal College of Nursing (RCN), said: “It is deeply alarming that over 5,000 young, early-career nursing staff chose to quit the profession last year, most vowing never to return. “When the vacancy rate is high and care standards often poor due to staffing levels, the NHS cannot afford to lose a single individual. “New ministers have to grasp the nettle and make nursing an attractive career.” Read full story Source: The Independent, 19 July 2024
  6. Content Article
    The Nursing & Midwifery Council (NMC) are the independent regulator for nurses and midwives in the UK and nursing associates in England. Their annual report sets out their objectives, describes what they have achieved during the year and explains their governance, financial resources and future plans. 2023-24 was a difficult year for the NMC during which serious concerns were raised about its culture and regulatory decision making. A review was commissioned by Nazir Afzal OBE and Rise Associates, which highlighted safeguarding concerns and found that people working in the organisation have experienced racism, other forms of discrimination and bullying. The NMC also commissioned two independent investigations by Ijeoma Omambala KC into some of their fitness to practise cases and the way the NMC handled whistleblowing concerns being raised. These will be published later in 2024.
  7. News Article
    BBC reporters are at Queens hospital in Romford, east London, and, like many across the capital it is busy. Really busy. When filming, 17 patients from their A&E were being treated on beds in corridors. Growing numbers of attendances have meant that what was once an emergency measure has now become the norm. Ruth Green is the director of nursing for the emergency department and says corridor care has become "customary practice" When the BBC last filmed the corridor treatments here back in January 2023, the department was seeing 1,400 patients arrive each month by ambulance. Now that number has risen to 2,100. The number of ambulances arriving every day has gone up in a year too, from around 90 per day to around 120. Ruth Green, the director of nursing for the emergency department said: "Unfortunately it is now customary practice to have patients treated on our corridors pretty much all of the time, not every day now it’s the summer, but still far too often." They have had to install new plugs in the corridors so they can operate the hospital beds, new nurse call buttons and a new sink. One patient in a bed in the corridor is Louis Vella. He spent 18 hours in A&E after coming in with chest pains and was eventually transferred to a corridor to wait for a bed on a ward. He said: "It’s not ideal, no, but they are working as best they can with what they’ve got and what else can one ask for?" Read full story Source: BBC News, 19 July 2024 Related reading on the hub: A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift Reflections on a clinical shift: "After 20 years of nursing, this is one of the worst shifts I have ever completed"
  8. News Article
    A troubled mental health trust’s internal mortality review has concluded 418 of an estimated 12,503 patient deaths over a four-and-a-half year period were “unexpected and unnatural”. Norfolk and Suffolk Foundation Trust’s leaders said the findings showed there had been a “much, much smaller” number of avoidable deaths than had been implied by previous reviews and reported by the media in the past. But the review’s findings were swiftly dismissed by campaigners, who said they had “no confidence” in the new figures, accused the trust of “corporate gaslighting” and renewed calls for a statutory public inquiry. The review was initiated after a similar exercise by Grant Thornton last June concluded it was not possible to work out how many avoidable deaths there had been because of the trust’s poor data. A month later, BBC Newsnight reported evidence it had watered down criticism in the Grant Thorton report, with allegations of “weak” and “inadequate” governance in earlier versions of the report removed from the final version. The trust and auditor said the changes were due to “fact checking”. Read full story (paywalled) Source: HSJ, 18 July 2024
  9. News Article
    A woman has said her ovarian cancer diagnosis was delayed after her symptoms were wrongly dismissed as menopause or irritable bowel syndrome (IBS) – accusing her doctor of misogyny and medically gaslighting her. Sbba Siddique, a 55-year-old business owner, told The Independent that “unconscious bias and cultural incompetence” were also to blame for her delayed diagnosis. Ms Siddique, who lives in Berkshire, said she began to feel unwell around October 2021 but did not get diagnosed with late-stage ovarian cancer until March the following year. “I was feeling really tired all the time. I had no energy. I was piling on weight that wasn’t there previously despite not changing my eating habits. I was needing to wee more,” the mother of three recalled. “I was going back and forth with my GP trying to get an appointment. I couldn’t get a face-to-face – every consultation was on the phone or via online forms. That was part of the problem of the misdiagnosis.” Her GP was “very dismissive” of her symptoms and attributed them to IBS or the menopause, she added. “At the end of the day, I’m not the expert, the GP is – I believed him,” she said. Read full story Source: The Independent, 14 July 2024
  10. Content Article Comment
    I can't find that document anymore on NHSE's website. They have a page of resources here: NHS England » Mental health nursing And a contact england.mhworksteams@nhs.net that might be able to help you. There's also the National Mental Health & Learning Disability Nurse Directors Forum, I don't know if they have something similar? MHForum If you do find it, please let us know and we'll update the page. Thanks Sam
  11. Content Article
    Integrated care systems (ICSs) were created to increase collaboration in the health and social care sector and to enable the NHS, local authorities and other partners to take collective responsibility for improving health outcomes, reducing inequalities, delivering better value for money, and driving local social and economic development. This research from the King's Fund examines the development of ICSs by assessing their efforts to develop system-wide approaches to the recruitment, training and retention of staff. The findings are based on 24 in-depth interviews with local leaders in four case study sites plus a series of online workshops.
  12. Event
    Julie Thallon (Chair of Trustees at the Patients Association) and Alf Collins (Trustee of the Patients Association, and NHS England’s former National Clinical Director for personalised care) will be discussing the tools and strategies patients can use to prepare for clinical appointments. They will be discussing how patients can prepare to ask good questions, to actively engage in shared decision-making and to clearly describe their priorities when discussing their healthcare choices. There will be an opportunity for questions and answers. The webinar will be followed by the Patients Association's Annual General Meeting. Register
  13. Content Article
    Workers facing complex environments in the pharmaceutical industry could be helped to reduce risks by taking a different approach to human error. Instead of viewing people as the root of the problems and following a “blame, shame and retrain” model, companies could help to set them up for success using human factors thinking and working proactively. A recent CIEHF webinar on Human and Organisational Performance in Pharma explored the difference that could be made through steps including: Recognising risk and techniques for preventing error. Creating a roadmap for investigating human-related deviations. Improving communication, interviewing and coaching.
  14. News Article
    The former health secretaries Jeremy Hunt and Matt Hancock have been criticised for their failure to better prepare the UK for the pandemic, in a damning first report from the Covid inquiry that calls for an overhaul in how the government prepares for civil emergencies. Hunt, who was the health secretary from 2012-18, and Hancock, who took over until 2021, were named by the chair to the inquiry, Heather Hallett, for failing to rectify flaws in contingency planning before the pandemic, which claimed more than 230,000 lives in the UK. The government had focused largely on the threat of an influenza outbreak despite the fact that coronaviruses in Asia and the Middle East in the preceding years meant “another coronavirus outbreak at a pandemic scale was foreseeable”. Lady Hallett said that to overlook that was “a fundamental error”. “It was not a black swan event,” Hallett said in a 240-page report. It concluded: “The processes, planning and policy of the civil contingency structures within the UK government and devolved administrations and civil services failed their citizens. Ministers and officials were guilty of ‘groupthink’ that led to a false consensus that the UK was well prepared for a pandemic. Never again can a disease be allowed to lead to so many deaths and so much suffering.” In what families bereaved by Covid welcomed as a “hard-hitting, clear-sighted and damning analysis of how and why the UK found itself to be fatally underprepared”, Hallett said “preparedness and resilience for a whole-system emergency must be treated in much the same way as we treat a threat from a hostile state”. The arrival of another pandemic – “potentially one that is even more transmissible and lethal” – was a question of when, not if, she said, and “unless we are better prepared” it would bring “immense suffering and huge financial cost and the most vulnerable in society will suffer most”. Read full story Source: Guardian, 18 July 2024
  15. Content Article
    The Covid-19 Inquiry published its first report and recommendations following its investigation into the UK’s ‘Resilience and preparedness (Module 1)’. The Chair of the Inquiry, Baroness Heather Hallett, set out her recommendations from the Module 1 report in a live streamed statement. It examines the state of the UK’s central structures and procedures for pandemic emergency preparedness, resilience and response. Reports related to the Inquiry’s further Modules will be published later.
  16. News Article
    The NHS should help social care recruit and retain nurses, including with better pay and conditions, particularly for new service models where care staff take on more health tasks. This is among the recommendations in the first workforce plan for adult social care, published by Skills for Care today, which also warns government must not delay promised improvements in staff pay, standards and conditions, while it waits to decide on funding reform. The report also recommends a pay uplift for care staff which it estimates would cost between about £2bn and £6bn a year – but it suggests there would be a significant net benefit overall due to reducing turnover costs and increasing care capacity. The report says integrated care systems should develop joint “one workforce” plans, “align terms and conditions, training and wellbeing support”, and “create the pipeline for registered nurses and nursing associates” to go into care roles. Nursing turnover in care providers is very high and it is thought nurses often leave for NHS jobs with better pay and conditions. However, nursing staff are increasingly needed to supervise “delegated healthcare tasks” for care users with rising acuity. It is an approach government, and many systems, want to grow as part of integrated teams, such as testing and monitoring in “virtual wards”. Read full story (paywalled) Source: HSJ, 18 July 2024
  17. Content Article
    For the first time ever, the adult social care sector has come together, led by Skills for Care, to develop the Workforce Strategy it needs. Adult social care needs a workforce strategy to ensure we have enough of the right people with the right skills to provide the best possible care and support for the people who draw on it.
  18. Community Post
    Post on X from Sharon Brennan Sharon Brennan on X: "Almost in tears at the pharmacy when told Creon is out of stock until end of the year and no alternatives available- suggested I buy it abroad but it’s expensive - or speak to dietician about my diet - I can’t eat without Creon so not sure what diet they can suggest!" / X
  19. News Article
    The NHS has significantly reduced the amount of IVF procedures it provides across the UK, leaving infertile women either unable to access treatment or forced to pay for it privately. Barely one in four (27%) of cycles of IVF during 2022 were paid for by the health service – the lowest figure since 2008 and a sharp fall on the 40% which it provided in 2012. The sharp fall in recent years is revealed in the latest annual report by the Human Fertilisation and Embryology Authority (Hfea), which regulates fertility treatment in the four home nations. The National Institute of Health and Care Excellence (Nice) has told the NHS in England to give all women who qualify three cycles of IVF. However, that rarely happens, with provision being patchy. Dr Kevin McEleny, the chair of the British Fertility Society (BFS), said women are the casualties of a widespread variation in the availability of IVF which is “heartbreaking and so unfair”. “Cost-cutting by NHS funding bodies who should implement the Nice IVF recommendations [means] patients in one part of the country are unable to access NHS-funded fertility treatments that people in a similar situation elsewhere in the country can. “Infertility is recognised as a health problem. Yet many people still see involuntary childlessness as a lifestyle choice, and this attitude reflects why it doesn’t get the NHS funding it deserves,” he added. Read full story Source: The Guardian, 18 July 2024
  20. News Article
    Organ replacement procedures to obesity surgery, Brazilian butt lifts to hair transplants and full body MOTs. This is not the body modification menu of a sci-fi novel, but packages for sale at the Health Tourism Expo – a two-day sales conference for surgical alterations held in London last month. The event was teeming with doctors and hospital representatives staffing promotional stands, many of them from Turkey where clinics attract thousands of British tourists looking for surgical alterations at a lower price, with flights and accommodation thrown in. There is no suggestion that any of the clinics exhibiting at the London expo have been involved in malpractice, but while the business of surgical tourism appears to be booming, one aspect of the industry seem to be missing entirely: regulation of promotional events such as this one. According to data from the Foreign Office, six Britonsa died in Turkey in 2023 after medical procedures, while data from the British Association of Aesthetic and Plastic Surgeons (BAAPS) has revealed the number of people needing hospital treatment in the UK after getting cosmetic surgery abroad increased by 94% in three years, with 324 patients requiring surgery once they returned home in the four years to 2022. Marc Pacifico, the president of BAAPS, said the lack of oversight of events such as the Health Tourism Expo was concerning. “I think it is truly remarkable that an exhibition like this seems to fall between the cracks of all the UK regulatory bodies that are responsible for healthcare and the safety of patients,” he said. “I would have thought it would be common sense for there to be some sort of oversight.” Read full story Source: The Guardian, 18 July 2024
  21. News Article
    The failures and weaknesses in the UK's pandemic preparations are expected to be laid out in the first report published by the Covid inquiry. Baroness Hallett, who is chairing the public inquiry, will set out her findings at lunchtime. Her report will cover the state of the healthcare system, stockpiles of personal protective equipment (PPE) and the planning that was in place. It is the first of at least nine reports covering everything from political decision-making to vaccines and the impact on children. Trained army medic Dr Saleyha Ahsan, who worked in hospitals during the first two waves of Covid and is now part of the Covid-19 Bereaved Families for Justice UK group, after losing her father to the virus, said it felt like there had been “zero planning”, with doctors often struggling to get hold of the right PPE “The rules were changing on a daily basis in the first few weeks - it was ridiculous,” she said. “We were in the flimsiest of PPE, just a little surgical mask with a white apron. “It felt like we were making do and the people who were being pushed to the front were healthcare workers." “It's so, so important for those of us who worked through it, who lost through it, or who have suffered ill health because of it, to really appreciate where things went wrong and who was responsible.” Read full story Source: BBC News, 18 July 2024 Related reading on the hub: The pandemic – questions around Government governance: a blog from David Osborn Respiratory protective equipment: An unequal solution for healthcare workers? A blog by David Osborn
  22. News Article
    More than one million extra women could have life-saving cervical-cancer checks if the NHS adopted do-it-yourself testing, researchers estimate. The team at King’s College London said the results of its self-testing trial were “fantastic” and “gave power to women”. The kits are like a Covid swab but longer and are posted to a lab for analysis. The NHS called the findings extremely positive and is assessing whether to roll out the scheme. There are more than 3,000 new cases of cervical cancer in the UK each year. “Cervical cancer screening has been in decline for the last 20 years,” a senior consultant on the trial, Mairead Lyons, said. "Many women will describe it as an uncomfortable experience [or they are] too busy, embarrassed or afraid of the physical experience of it." NHS England screening and vaccination director Deborah Tomalin called the trial results “extremely promising”. “The NHS will now be working with the UK National Screening Committee to consider the feasibility of rolling this out more widely across England,” she said. Read full story Source: BBC News, 17 July 2024
  23. News Article
    More than 133,000 men die early every year in the UK, equating to 15 every hour, according to a report calling for urgent action to improve men’s health. Two in five men are dying prematurely, before the age of 75 and often from entirely avoidable health conditions, research by the charity Movember found. Almost two in three men – 64% – wait more than a week before visiting a doctor with symptoms, while 48% believe it is normal practice to avoid health check-ups. Less than 40% take up the offer of an NHS health check for which they are eligible. “The report findings should serve as a wake-up call to the unacceptable state of men’s health across the UK,” said Michelle Terry, the chief executive of Movember. “For too long, men’s health has been relegated to the sidelines of broader health conversations. Men’s health doesn’t exist in a vacuum.” The report found the health of men in the UK was worse than in many other wealthy countries, while those living in the UK’s most deprived regions are 81% more likely to die prematurely than those in the wealthiest. William Roberts, the chief executive of the Royal Society for Public Health, said: “Too many men are dying too young and too many men experience poor health due to preventable conditions. “It is critical that we address the underlying causes of poor men’s health. Men’s health affects us all and we need to see it as a critical part of a healthy nation.” Read full story Source: The Guardian, 17 July 2024 Further resources on the hub: 11 top picks: Men's health Why harmful gender stereotypes surrounding men’s approaches towards their feelings need challenging
  24. News Article
    The proportion of trusts with maternity services “red rated” for neonatal mortality rose from around a quarter in 2021 to a third in 2022, according to the latest national audit. The latest Mothers and Babies: Reducing Risk Through Audit and Confidential Enquiries report, published on Friday, classifies trusts from red to green, according to how far above or below they are their peer group providers. Nationally, there were increases in the neonatal mortality rate per 1,000 live births in 2022 compared with 2021, rising from 1.65 to 1.69 per 1,000 total births. Neonatal death is when a baby dies in the first 28 days of life. Of 121 trusts, 41 (34%) were rated “red” for neonatal mortality in 2022, as their rates were over 5% higher than their peer group average. This compares with 32 trusts (26% of 123 trusts) rated “red” for neonatal mortality in 2021. There were, however, also some areas of improvement year-on-year. The number of trusts rated “green” — with neonatal death rates more than 15% lower than the average in their peer group — increased from three in 2021 to eight in 2022, marking a significant improvement from 2020 and 2021. Read full story (paywalled) Source: HSJ, 17 July 2024
  25. Content Article
    This is the tenth MBRRACE-UK Perinatal Mortality Surveillance Report. The report is divided into five sections: perinatal mortality rates in the UK; mortality rates for Trusts and Health Boards; mortality rates by gestational age; mortality rates by ethnicity and socio-economic deprivation; and a description of the causes of perinatal death. This report focuses on births from 24 completed weeks’ gestational age, with the exception of the section on mortality rates by gestational age, which also includes information on births at 22 to 23 completed weeks’ gestational age. This avoids the influence of the wide disparity in the classification of babies born before 24 completed weeks’ gestational age as a neonatal death or a late fetal loss. Terminations of pregnancy have been excluded from the mortality rates reported. Additional supporting materials to accompany this report include: a set of reference tables a data viewer with interactive mapping, which presents mortality rates for individual organisations, including Trusts and Health Boards a technical manual containing full details of the MBRRACE-UK methodology, including definitions, case ascertainment and statistical methods.
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