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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    In the latest Office for National Statistics survey, published in April, 111,816 children (aged three to 17) in England and Scotland were estimated to be suffering from Long Covid during the four-week period ending 7 March. More than 20,000 of these children have found their ability to undertake day-to-day activities has been “limited a lot”. For Toby, it has meant pain, crushing fatigue and sadness – as well as months off school. Dr Binita Kane is a Manchester-based consultant respiratory physician with a special interest in Long Covid. Her experience comes from being a doctor treating patients with Long Covid and also being the mother of a girl with Long Covid. She says that the 2 million people struggling with Long Covid in England and Scotland have created a massive challenge for the health service. The model for post-Covid services was set up in 2020, and in terms of scale and pace the UK was ahead of the game then. But things have moved on and the NHS hasn’t kept up. “The NHS is a juggernaut,” Kane says. “It cannot change things in a rapid way unless you put the weight of everything behind it, like we did in acute Covid.” Read full story Source: The Guardian, 12 June 2024
  2. Content Article
    Phil, Triangle of Care lived experience co-chair at Pennine Care NHS Foundation Trust, shares a short message about why involving carers in patient safety work and sharing expertise with carers is so important.
  3. News Article
    HSJ understands that IT systems across the Cornwall and Isles of Scilly ICS went down around midday, prompting the declaration of a major incident. In a statement, a spokesperson for the ICS said the incident was a “local issue” and not a “cyber attack”. As a result of the issue, some planned outpatient appointments, including operations, have been cancelled. The outage is also thought to have contributed to a large ambulance handover backlog. Royal Cornwall Hospitals NHS Trust, Cornwall Partnership NHS Trust, and University Hospitals Plymouth NHS Trust, as well as GP surgeries and community providers, are understood to have been affected by the outage. Read full story (paywalled) Source: 11 June 2024
  4. News Article
    People aged 65 and over arriving at A&E in England who appear frail will soon receive a “health MOT at the front door”, the head of the NHS will pledge. A&E units must start giving everyone that age a battery of tests to see if they are frail or have any other underlying condition and then arrange whatever care they may need. NHS England hopes the initiative will reduce the number of older people being admitted to hospital, and cut overcrowding, “trolley waits” and “corridor care”. Amanda Pritchard, the organisation’s chief executive, will tell an audience of health service heads on Wednesday they must ensure by next April that all A&E units start offering detailed assessments of older people’s health. However, the service will only operate for 10 hours a day. “Health MOTs at the front door of A&Es for older people could be a lifeline for many. From blood pressure tests to a review of their falls history, these checks mean patients can be assessed quickly and directed to the right support for their needs,” Pritchard will say. “While some people do need to be admitted, it isn’t always the most suitable place for older patients’ needs, and they can also rapidly lose mobility while in hospital.” Read full story Source: The Guardian, 12 June 2024
  5. News Article
    “Outdated” guidance on prostate cancer could be putting men’s lives at risk, a charity has said. Prostate Cancer UK said that men at high risk of the disease can get a test, but only if they request one. It said that GPs are told not to raise the issue with men unless they have symptoms. But most men with early prostate cancer – when it is easiest to treat – do not have any signs or symptoms. Chiara De Biase, director of health services, equity and improvement at Prostate Cancer UK, said: “We simply can’t continue with a system where men at high risk of prostate cancer can get a test – but only if they know to request one. “This outdated guidance is failing both men and their clinicians, making health inequalities worse and putting lives at risk. It’s about time that changed. She added: “We know that a lot of men don’t come forward because they think they’ll be invited as part of routine tests – when this simply isn’t true". Read full story Source: The Independent, 12 June 2024
  6. News Article
    A new service in Somerset is being set up to support women who have had adverse outcomes during pregnancy. Maternity and neonatal independent senior advocates (MNISA) say they will act on behalf of women if they feel their experience when being cared for during pregnancy led to something going wrong. This can include death, babies being diagnosed with brain injuries or mothers needing critical care. MNISAs can attend meetings or support users through investigations and complaints. The service will be piloted until next year and while the role is independent from the maternity and neonatal trust provider (Somerset NHS Foundation Trust), it sits within NHS Somerset. Jane Innes, a qualified lawyer who has worked across the NHS for 30 years, will take up the new role in Somerset. She said: "There is an acknowledgement that people's voices need to be heard and listened to so systems can act and respond appropriately." Read full story Source: BBC News, 11 June 2024
  7. Content Article
    Your Care Needs You! is designed to empower, encourage and support patients and their families to know more and do more in hospital, so that people have the skills and confidence to manage their own health and care more safely when they return home. These are resources to guide patients and families through the key things to do in hospital to prepare for living at home again.
  8. Content Article
    The Triangle of Care is a therapeutic alliance between carers, service users and health professionals. It aims to promote safety and recovery and to sustain mental wellbeing by including and supporting carers.
  9. Content Article
    This template standardises the reporting of After Action Reviews (AARs). It is not intended to be an AAR facilitation guide. The template has been co-designed with staff leading AARs in a range of healthcare organisations. The structure is purposefully simple so that AARs can focus on reflective conversation and do not become a bureaucratic documentation exercise. This structure will continue to be evaluated and developed by the National Patient Safety Team. It can be downloaded from the attachment below or it's available on FutureNHS within the AAR tool space here: https://future.nhs.uk/NHSps/view?objectId=42826256 
  10. Content Article
    Hand hygiene is crucial in healthcare settings, especially in maternity units. This poster developed by the World Health Organization (WHO) shows the five key moments for hand hygiene care in a maternity unit.
  11. News Article
    Hundreds of patients are being harmed each year because NHS organisations have incorrectly identified who they are, an HSJ investigation has found. Responses to Freedom of Information requests from 166 trusts revealed 58,537 cases of patient misidentification logged in Datix or other patient safety systems between 2019 and 2023, including 4,713 causing some sort of harm. This is equivalent to 11,707 incidents a year, with 943 leading to harm. It includes a wide range of errors, but harm typically happens when patients are given the wrong treatment or medicine, or miss out on the right treatment, as a result of errors in recording and/or miscommunication. A typical example is patients being given a wristband with the wrong name – or ID information resulting in patients not being treated, or the wrong treatment being given. Some of the worst examples are where the wrong patient, or the wrong part of the body, is operated on. Patient Safety Learning's CEO Helen Hughes called on NHS England to review cases nationally to identify root causes. She added: “Where avoidable harm has occurred, it is vital these incidents are investigated, that causes and contributory factors are identified, and steps put in place to prevent their reoccurrence. In some cases, this may require standardisation of approaches to patient identification, while others may highlight contributory factors that are more difficult to address, such as staff fatigue.” Read full story (paywalled) Source: HSJ, 11 June 2024
  12. Content Article
    Medical device industry payments to healthcare organisations (HCOs) can create conflicts of interest which can undermine patient care. One way of addressing this concern is by enhancing transparency of industry financial support to HCOs. MedTech Europe, a medical device trade body, operate a system of disclosure of education payments to European HCOs. This study aimed to characterise payments reported in this database and to evaluate the disclosure system.
  13. Content Article
    Involving patients is a key premise of national and international policies on patient safety, which requires understanding how patients or carers want to be involved and developing resources to support this. This paper examines patients' and carers' views of being involved in patient safety in primary care and their views of potentially using a co-designed patient safety guide for primary care (PSG-PC) to foster both involvement and their safety. It found that involving patients and carers in patient safety needs a tailored and personalised approach that enables patients and carers to use resources like the PSG-PC routinely and helps challenge assumptions about their willingness and ability to be involved in patient safety. Doing so would raise awareness of opportunities to be involved in safety in line with personal preference.
  14. Content Article
    The relentless increase in administrative responsibilities, amplified by electronic health record (EHR) systems, has diverted clinician attention from direct patient care, fuelling burnout. In response, large language models (LLMs) are being adopted to streamline clinical and administrative tasks. Notably, Epic is currently leveraging OpenAI's ChatGPT models, including GPT-4, for electronic messaging via online portals. The volume of patient portal messaging has escalated in the past 5–10 years, and general-purpose LLMs are being deployed to manage this burden. Their use in drafting responses to patient messages is one of the earliest applications of LLMs in EHRs. Previous works have evaluated the quality of LLMs responses to biomedical and clinical knowledge questions; however, the ability of LLMs to improve efficiency and reduce cognitive burden has not been established, and the effect of LLMs on clinical decision making is unknown. To begin to bridge this knowledge gap, the authors of this study, published in the Lancet, carried out a proof-of-concept end-user study assessing the effect and safety of LLM-assisted patient messaging.
  15. Content Article
    Medication safety in care homes is an ambitious cross-sector partnership project aiming to improve the medicines pathway for residents in care homes.
  16. Content Article
    Patient safety policies increasingly encourage carer (i.e., family or friends) involvement in reducing health care–associated harm in hospital. Despite this, carer involvement in patient safety in practice is not well understood—especially from the carers’ perspective. The purpose of this article is to understand how carers of adult patients perceived and experienced their patient safety contributions in hospital. Constructivist grounded theory informed the data collection and analysis of in-depth interviews with 32 carers who had patient safety concerns in Australian hospitals. Results demonstrated carers engaged in the process of “patient-safety caring.” Patient-safety caring included three levels of intensity: low (“contributing without concern”), moderate (“being proactive about safety”), and high (“wrestling for control”). Carers who engaged at high intensity provided the patient with greater protection, but typically experienced negative consequences for themselves. Carers’ experiences of negative consequences from safety involvement need to be mitigated by practice approaches that value their contributions.
  17. Content Article
    Exposure documentary exploring the failures in maternity care at the Nottingham University Hospitals Trust (NUH), and the toll it has taken on those fighting for justice.
  18. News Article
    A combined flu and coronavirus vaccine brings about a higher immune response to both diseases than when the vaccines are administered separately, a clinical trial has shown. Moderna, the biotech firm behind the Spikevax vaccine used in NHS booster programmes, is trialling a two-in-one jab that can also protect from the flu. Initial results have shown it may be better at protecting against them than what is now being used. The results showed that the antibody response in the participants brought about higher immune responses against flu and Covid-19 than when the vaccines were administered separately. Stéphane Bancel, the chief executive of Moderna, said: “Combination vaccines have the potential to reduce the burden of respiratory viruses on health systems and pharmacies, as well as offer people more convenient vaccination options that could improve compliance and provide stronger protection from seasonal illnesses. Read full story Source: The Guardian, 10 June 2024
  19. News Article
    A landmark study has compared the risk of complications of water births. The results could have implications for thousands of women each year who use birthing pools as a form of pain relief during labour, researchers said. It concluded having a water birth does not increase the risk of complications for mother or baby. The Pool study analysed 73,229 records from low-risk pregnant women who used a pool during labour across 26 NHS organisations in England and Wales between 2015 and 2022. The team explored the rate of severe tears suffered by women during childbirth, as well as the number of babies who needed antibiotics or help with breathing on a neonatal unit after birth. They also looked at the number of babies that died. According to researchers, risks “were no higher among waterbirths compared with births out of water”. Read full story Source: The Independent, 11 June 2024
  20. News Article
    The first NHS AI-run physiotherapy clinic is to be rolled out this year in an effort to cut waiting times amid growing demand and staff shortages. The new platform will provide same-day automated video appointments with a digital physiotherapist via an app that responds to information provided by a patient in real time. It is the first platform of its kind to be approved by the health regulator, the Care Quality Commission, as a registered healthcare provider. Patients seeking physiotherapy for issues such as back pain can be referred to the platform Flok Health through a community or primary care healthcare setting, such as their GP. They can also self-refer directly into the service. The service aims to provide faster care and reduce waiting times and pressure on clinicians, those behind it say. However, some in the industry say that AI cannot yet replicate the skill of a fully trained physiotherapist, and that treatment needs to be nuanced due to the complexity of cases. CSP health informatics lead, Euan McComiskie, said of the AI clinic: “There is no doubt that more needs to be done to tackle huge NHS waiting lists, particularly for musculoskeletal services and AI has huge potential to be an adjunct to the work of physiotherapists. However, AI cannot yet replicate the clinical judgment and skills of a physiotherapist, who is required to be registered with a statutory regulator, the Health and Care Professions Council (HCPC).” McComiskie added that physiotherapists manage “increasing complexity in patient presentation and their treatment needs to be individually tailored”. He said: “It is early days to know how much AI can eventually provide clinical decision making and more research is needed … but not at the cost of patient access, safety, experience nor trust.” Read full story Source: The Guardian, 9 June 2024
  21. Event
    Safe and appropriate use of medicines in an ageing population is a complex balance between managing disease and avoiding medication-related problems. As the population ages, more Australians are living with multiple chronic diseases and may take multiple medicines, which is known as polypharmacy. This puts them at increased risk of medicine-related problems. Optimal medication management in older people requires a team-based approach to ensure the best quality of life. NMS 2024 will bring together leading organisations, experts, clinicians, consumers and policymakers within the aged care sector for a timely discussion on emerging and key issues around medicine safety in older people and will have a strong focus on highlighting practical ideas and initiatives that could be incorporated to improve the safe and quality use of medicines in an ageing population. Further information
  22. Content Article
    On the 8 March 2023, an investigation commenced into the death of Christine Rita Booker, born on the 6th October 1943. The investigation concluded at the end of the Inquest on the 17 May 2024. The medical cause of death was: la Haemorrhagic shock   lb Iatrogenic injury of right pelvic blood vessels 2 The conclusion of the Inquest recorded that Christine Rita Booker died as a consequence of a complication of elective hip replacement surgery.
  23. News Article
    A 79-year-old woman bled to death following a hip operation after being rushed to a hospital which lacked a service to save her, a coroner has said. Christine Booker from Wareham died on 24 February 2023, the day after her hip replacement. Coroner Brendan Allen said she was initially transferred to Dorset County Hospital in Dorchester, which had no out-of-hours interventional radiology (an imaging procedure), before being sent to Royal Bournemouth Hospital. In a Prevention of Future Deaths report, he said patients in west Dorset faced a "potentially considerable and significant delay in the provision of urgent and life-saving treatment". Writing to Dorset County Hospital, external, the coroner said the lack of an out-of-hours service in Dorchester exposed patients to an "increased risk of death". Read full story Source: BBC News, 10 June 2024
  24. News Article
    Patients with cancer and those needing emergency operations were among those who had their treatment cancelled this week due to a major cyberattack on NHS hospitals in London. More than 200 emergency and life-saving operations, including those which should be done within 24 hours, had to be cancelled by Guy’s and St Thomas’ Foundation Trust (GSTT) and King’s College University Hospital NHS Foundation Trust. It is not yet clear how long the disruption will last, however hospitals are concerned they will struggle if it continues for more than a few days. According to a source, Synnovis carries out tens of thousands of tests a day but is unable to do so as it cannot access systems. The Independent revealed: More than a third of procedures and operations have been cancelled, which includes over 3,000 non-surgical appointments and hundreds of patients who have been referred for urgent cancer diagnosis. Mothers waiting to have c-sections have also had their procedures cancelled and hospitals are investigating potential harm. Transplant operations have been cancelled and hospitals have had to reduce the number of people they’re able to book in. Read full story Source: The Independent, 10 June 2024
  25. News Article
    An appeal has been launched for O blood-type donors to book appointments across England after the ransomware attack affecting major London hospitals. NHS Blood and Transplant is appealing for O blood-type donations as this is safe to use for all patients. The cyber-attack means the affected hospitals cannot match patients’ blood at the same frequency as usual. Several London hospitals last week declared a critical incident, cancelled operations and tests, and were unable to carry out blood transfusions after the attack on the pathology firm Synnovis, which Qilin, a Russian group of cybercriminals, is thought to have been behind. Memos to NHS staff at King’s College hospital, Guy’s and St Thomas’ (including the Royal Brompton and the Evelina London Children’s hospital) and primary care services in London said a critical incident had been declared. NHS Blood and Transplant is calling for O-positive and O-negative blood donors to book appointments in one of the 25 NHS blood donor centres in England to boost stocks. The hospitals affected by the cyber-attack cannot match patients’ blood at the same frequency as usual, NHS Blood and Transplant said. For surgeries and procedures requiring blood to take place, hospitals need to use O-type blood as this is safe to use for all patients. Blood has a shelf life of 35 days, so stocks need to be continually replenished, the NHS said. Read full story Source: The Guardian, 10 June 2024
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