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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    This blog is part of a series written by Dr Charlie* taking a closer look at some of the patient safety issues affecting people's lives today.  In this blog, Dr Charlie describes how although digital prescribing can work well it needs all those involved in the system to put their heart and soul into it. Families and patients must be involved, drugs prescribed must be regularly reviewed and care must be joined up. *Names have been changed in this blog.
  2. News Article
    The NHS has been told it can start using a new digital test to speed up the diagnosis of ADHD in children and young people, which up to now could often take several years. The National Institute for Health and Care Excellence (NICE) has issued draft guidance approving the use of the QbTest by psychiatrists and specialist children’s doctors. The computer-based test measures the three main characteristics of ADHD: inattention, impulsivity and hyperactivity. Clinicians can use the results alongside other information they have gathered to help them diagnose, or rule out, that a young person has the condition. NICE said the test could be used when diagnosing six- to 17-year-olds in England and Wales. Experts welcomed the move, saying the QbTest would help doctors diagnose more people within six months of them first being assessed. Dr Jessica Eccles, the chair of the Royal College of Psychiatrists’ neurodevelopmental special interest group, said: “People who suspect they may have ADHD often have to wait months or even years for an assessment which can prevent them from accessing timely and effective care. Any new evidence-based tools should be used to reduce these unacceptable waiting times and improve the availability of support.” Read full story Source: The Guardian, 16 July 2024
  3. News Article
    A Black nurse who tried to call out alleged racism at a scandal-hit regulator was targeted by a complaint, The Independent revealed. The Nursing and Midwifery Council (NMC), which regulates more than 800,000 nurses and midwives in the UK, was heavily criticised in a review that found it had a “toxic” and “dysfunctional” culture and had failed to address racism in its ranks. The review warned that the safety of the public as well as nursing and midwifery staff is at risk because of flawed and delayed investigations by the NMC. It warned of widespread allegations of racism at the NMC, which senior leaders had failed to address. It also found that the body was mishandling racism complaints against nurses and midwives. Staff told reviewers that prejudice such as racism and misogyny was leading to flawed responses to complaints against nurses. Now a Black nurse, Neomi Bennett, has revealed that she faced a complaint submitted by a senior NMC representative after she publicly called out alleged racism on the part of the regulator. She told The Independent that being referred to her regulator for her comments while calling out racism felt like a “betrayal” and an “abuse of power”. Read full story Source: The Independent, 15 July 2024
  4. News Article
    A sexual health nurse who failed to tell patients and their partners of positive test results for sexually transmitted infections should be struck off, a professional hearing was told. David Allen made incorrect entries and omitted information when updating patient records, the Nursing and Midwifery Council (NMC) heard. Mr Allen, who worked at Wakefield Integrated Sexual Health Services, also posted abusive and inappropriate messages about colleagues online. The NMC found his actions could have resulted in a real risk of harm to patients and had been "a flagrant departure from the standards expected of a registered nurse". The NMC panel, which met earlier in July, heard the discrepancies dated back to 2018 and involved 18 cases. When a person has tested positive for a sexually transmitted disease, guidelines said any current or past sexual partners should be informed, which is called partner notification. The NMC panel found that on 18 occasions, Mr Allen had failed to complete the partner notification and had falsely indicated he had done so. Read full story Source: BBC News, 15 July 2024
  5. News Article
    A woman living with type 1 diabetes is calling for better communication on the supply of essential medication after she had to turn to social media for help in finding some. Gwen Edwards, 27, from Anglesey, takes insulin and has been using Fiasp FlexTouch, a type of insulin that comes in a disposable pen. A shortage notice about supplies of the insulin that she uses was sent to all surgeries and pharmacies in Wales in March, but Gwen said she was not made aware of this. According to her, she normally gets a prescription two weeks before her medicine runs out, but recently it became clear that there was a problem with the stock. "I had to go and look for insulin. One chemist told me that they had run out and that there was no stock at all, so I was a bit worried," she said. Despite the low stock, she said she was not aware of the shortage. "I went with the prescription to other places to look for the insulin. Five chemists later they told me that the insulin was out of stock." Her GP practice said it could not comment on individual cases, but the health board for north Wales said local pharmacies would not "routinely contact patients directly" about shortages of medicines because most would not see any disruption. Read full story Source: BBC News, 15 July 2024
  6. News Article
    Two babies died on a hospital’s neonatal intensive care unit during a bacterial outbreak which could have been prevented, the BBC has learned. An internal investigation by Bradford Royal Infirmary (BRI) said lapses in hygiene practices allowed the drug-resistant bugs to spread. Five other infants were found to have the same Klebsiella pneumoniae strain during the outbreak in November 2021. The mother of a two-week-old boy who died said she felt “betrayed” by the hospital and had begun legal action. Bradford Teaching Hospitals NHS Trust said it had implemented new infection control measures, brought in additional training and increased staffing levels. A nurse who previously worked at the neonatal unit told the BBC staff faced “extremely strenuous” conditions which led to “medical mistakes”. A patient safety incident investigation report, circulated internally in March 2022 and seen by the BBC, also said infection control practices which could have stopped the spread of Klebsiella “were not being implemented consistently” by staff in the unit. It revealed an investigation had found staff in the neonatal unit were not “consistently” following hand hygiene guidelines at the time of the outbreak and “seemed unclear” about where and when personal protective equipment was required. Read full story Source: BBC News, 16 July 2024
  7. Content Article
    Seminar from Tracey Herlihey, NHS England, on the Patient Safety Incident Framework (PSIRF).
  8. Event
    To participate in the webinar, please use the following link: https://echo.zoom.us/j/84588891736
  9. Event
    The landscape of commissioning, its arrangements and responsibilities are regularly shifting and can be complex. The terminology used may change but whether it is called commissioning, strategic commissioning or population health management it is important to recognise that effective health services need to be properly planned, designed and resourced – so the work of commissioning is, and will remain, vital. Join this two-day virtual event from the King's fund to be at the forefront of discussions about how the narrative around commissioning and its future is changing, and how organisations from different parts of the sector can get involved in designing and improving the services, both for those working in the health and care system and for the people and communities who use health services. Sessions will bring together individuals and teams across the health and care system to showcase different examples of how commissioning is being used to plan and transform services. These will aim to inspire you to think differently about commissioning and the way organisations can work together to achieve effective commissioning process across the health and care system. It will also explore how regions, integrated care boards and place-based partnerships will need to work together to design, improve and deliver services. You will also learn how the culture around commissioning, planning and improvement is changing as the system moves towards a more collaborative approach. Register
  10. Content Article
    Patient safety is seen as implicit and complex, difficult to measure, difficult to engage with and the area of experts. This is very different from high safety industries that put safety at the centre of their activities, with a leadership intent to develop a just and learning culture. In this blog, Henrietta Hughes highlights the importance of leadership, not only of provider organisations but all the bodies that surround the NHS – the politicians, officials, inspectors, regulators, commissioners, representative bodies and patient groups. For frontline staff and patients alike, it is vital that leaders speak the same safety language, understand the impact that they have on the safety culture and embrace patient partnership.
  11. News Article
    Vulnerable people face being denied basic preventive social care at home due to a wave of rapid discharges from hospitals that is sucking up resources, council bosses have warned. Despite cross-party support for more early care at home, town hall officials are having to allocate resources to people with more complex needs, many discharged from hospital early as part of attempts to clear NHS backlogs. It means thousands of others were “at risk of missing out [on care] or their needs escalating”, warned the Association of Directors of Adult Social Services in England (Adass) after its annual survey of England’s 153 council social care directors. It revealed that only 1 in 10 directors were fully confident their budgets would meet their statutory duties – down from more than a third before the Covid pandemic. Spending aimed at preventing people’s conditions from worsening was forced down by £121m over the past year. As the complexity of cases increases, councils overspent by £586m – the highest level for at least a decade, triggering raids on dwindling council reserves. The findings were “unsustainable and worrying” said Melanie Williams, the president of Adass and director of adult social care at Nottinghamshire county council. “Instead of focusing on investment in hospitals and freeing up beds, the new government must shift to investing in more social care, supporting unpaid carers, and providing healthcare in our local community to prevent people reaching crisis point and ending up in hospital in the first place,” she said. Read full story Source: The Guardian, 16 July 2024
  12. News Article
    The UK’s under-fire nursing regulator is being forced to investigate as a third of universities may have released trainee nurses to work in hospitals despite failing to carry out hundreds of hours of mandatory training. The potential training failure comes after the Nursing and Midwifery Council (NMC) allegedly ignored warnings from universities about the problem three years ago, with the regulator only now taking action. The blunder means an unknown number of nurses may have been sent to work in hospitals without the required amount of experience, and hundreds of student nurses have already had their graduation date delayed, leaving some concerned about public safety. Thirty out of 98 universities are now facing reviews by the NMC into how they have monitored the qualifications of student nurses and midwives. Read full story Source: The Independent, 14 July 2024
  13. News Article
    One in five hospices in the UK are cutting services amid the worst funding crisis in two decades, a report has warned, with soaring numbers of patients being pushed back into the NHS. Research by Hospice UK found “small and wildly varying” state funding had failed to keep pace with growing demand and rising running costs. That means inpatient beds are being cut, staff made redundant and community services restricted, with fewer visits to dying patients in their own homes, according to the charity, which represents more than 200 hospices across the country. Hospice UK said the sector’s finances were in their worst state in 20 years. A fifth of hospices have cut or closed their services in the last year or are planning to do so, the charity said. Toby Porter, its chief executive, said: “Too many hospices are in crisis. The small and wildly variable amount of state funding they receive has failed to keep pace with rising costs. “Many hospices are therefore running deficits that can only mean one thing – more cuts to essential care services, or even service closures. We’re already seeing redundancies at some major hospices.” Read full story Source: The Guardian, 16 July 2024
  14. News Article
    The Care Quality Commission’s new chief executive has admitted the regulator “got things wrong” during the rollout of its new inspection regime and announced an increase in the number of assessments it carries out. The CQC announced a shake-up of its regulatory regime three years ago. It involved a move from a “set schedule of inspections to a more flexible, targeted approach”, called the “single assessment framework”, with greater reliance on data. However, its rollout has been controversial with CQC’s own staff and providers flagging concerns about the new approach. Now, Ms Terroni has said changes in how the regulator manages relationships has left many providers feeling “unsupported”, with wider technical issues preventing organisations from accessing information. She wrote: ”I want to start with an apology. We’ve got things wrong in the implementation of our new regulatory approach. I know that the changes we’ve delivered so far are not what we promised. It’s made things more difficult than they should be. We’re not where we want to be, and we’re determined to put things right…. “Many of the issues we’re experiencing now were anticipated and flagged by providers and our own people. We didn’t listen properly or take on board these concerns, and that’s why we’re where we are now. “Though there was significant engagement and co-production of the high-level elements of our approach, we didn’t follow that process into the detail of how we’ll assess providers. I know that, for some of you, we’ve lost your trust because of this. I’m sorry.” Read full story (paywalled) Source: HSJ, 15 July 2024
  15. Content Article
    The NHS wasn’t the only health system that experienced severe disruption of care during the pandemic, but how quickly have waiting times in England recovered in comparison to other nations? Sarah Reed and Theo Georghiou look at how waiting times have changed in England and in other countries since the peak of the Covid-19 crisis.
  16. News Article
    Waiting times for hip and knee replacements are four times longer in England than Italy post-lockdown, analysis has revealed. Patients in England are waiting an average of 128 days for hip replacements and 141 days for a new knee on the NHS, which are both up by around 50 per cent since before the pandemic. It leaves England lagging behind other European countries, with waits that are four times longer than Italy, where hip replacements are completed in 33 days and knees within 30 days, according to analysis by the Nuffield Trust. Sarah Reed, senior fellow at Nuffield Trust and author of the report, said countries around the world were “dealing with the effects of the Covid-19 pandemic, with many still struggling to bring down waiting times”. “However, it’s striking that in England our pace of recovery has been much slower for major surgeries like hip and knee replacements, but for some minor procedures we appear to have improved more quickly than nearly everywhere else,” she said. Read full story (paywalled) Source: The Telegraph, 11 July 2024
  17. Content Article
    Research on clinical deterioration has mostly focused on clinicians' roles. Although patients and families can identify subtle cues of early deterioration, little research has focused on their experience of recognising, speaking up and communicating with clinicians during this period of instability. This study explored patient and family narratives about their recognition and response to clinical deterioration and their interactions with clinicians prior to and during Medical Emergency Team (MET) activations in hospital.
  18. Content Article
    How do we make change happen at scale across a complex health system? When we look at the results of incident investigations, communication is the number one reason for things going wrong. We need to sign up to a common language for safety and a common understanding, says Patient Safety Commissioner Henrietta Hughes.
  19. Content Article
    In this episode of the Safety Talks podcast. you will have the chance to hear from Dr Ali Mehdi, Consultant Trauma & Orthopedic Surgeon and Medical Director of Kent & Canterbury Hospital on workplace identity and team work. Safety Talks is a podcast series as part of the Safety for All Campaign, launched to shine a light on the symbiotic relationship and benefits of integrating the approach to deliver healthcare worker safety and patient safety.
  20. Content Article
    Patients with endometriosis are having their symptoms dismissed and investigations delayed because of a lack of awareness among healthcare professionals of the chronic condition and how it presents, a report has found. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) set out to determine the quality of care provided to adult patients with endometriosis by reviewing questionnaire responses from 623 clinicians, 167 hospitals, and 941 patients and looking at 309 sets of case notes. The inquiry found that, unlike with other chronic conditions, there is no NHS care pathway for endometriosis.
  21. Content Article
    This toolkit is designed to support integrated care systems (ICSs) to design, plan, and deliver high-quality treatment and care for children and young adults aged 0-25 years with all types of diabetes.
  22. News Article
    There were "missed opportunities" to treat a four-year-old girl who visited A&E and a GP in the 48 hours before her death, an inquest jury has concluded. Makenna-Rose Thackray died on 20 December 2022 after stopping breathing and going into cardiac arrest. She was taken to Wakefield's Pinderfields Hospital by ambulance two days earlier but went home after her family endured a fruitless six-hour wait for treatment. They visited a GP the following day and were sent home without antibiotics. A lawyer for Makenna-Rose's family said the evidence showed the girl's death was "entirely preventable". On 18 December Makenna-Rose had been taken to children's A&E but the inquest heard the two nurses on shift that night dealt with almost 80 children, instead of the 30 to 40 which could have been safely treated. Earlier in proceedings, one of the nurses on shift that night, Helen Parker, described the shift as "one of the worst" and when asked if they were under-staffed, replied: "Absolutely, yes." Read full story Source: BBC News, 11 July 2024
  23. News Article
    Patients trying to reach their GP are almost three times as likely to fail to get through in the worst-performing integrated care systems (ICS) than the best, according to analysis of new annual figures. The data is from NHS England’s annual GP patient survey, which has a large sample size, and is considered one of the best measures of GP access and experience. In Birmingham and Solihull and Black Country, 7% of patients said their calls went unanswered — significantly lower than the best-performing systems at 2%, and the national average of 4%. Some more urban and racially diverse areas tended to do worse on key GP access measures – such as Birmingham, the Black Country, large parts of London, Greater Manchester, and Bedfordshire, Luton and Milton Keynes – although more rural patches like Northamptonshire and parts of the South West also have big problems. NHSE said in a statement: “NHS staff have worked incredibly hard to cope with increased demand for patient care, but this survey makes it clear there is much more to do to improve patient’s satisfaction and experience in accessing primary care services.” It will work with the government to “tackle the issues that matter most to patients” including long-term conditions, continuity of care and patient access, it added. Read full story (paywalled) Source: HSJ, 12 July 2024
  24. Content Article
    The Patient Experience Network National Awards (PENNA) recognise best practice in patient experience across all facets of health and social care in the UK. Submissions for PENNA 2024 are now officially open. Place these important PENNA dates in your diary for this year: 08/04/24 – PENNA Submissions Open 19/07/24 – PENNA Submissions Close 12/08/24 – PENNA Shortlist Announced Find out more at the link below.
  25. News Article
    A woman who is paralysed from the chest down is helping scientists in York develop a robot so people with mobility issues can receive breast screening. Jane Hudson, 53, from Harrogate, was unable to get an accurate mammogram because she could not get into the right position for the X-ray machine. She was diagnosed with breast cancer a few months later. Scientists at the University of York have now started working on a prototype robotic arm system which will support the patient's upper body weight. Ms Hudson said: "I've faced many difficulties and challenges in the wheelchair and you do sometimes feel like you don't get listened to, so for something positive to come out of this is great." Ms Hudson was invited for a mammogram at York Hospital because it was accessible but she was unable to position herself correctly in the machine for an X-ray to take place. She said: "I did feel really humiliated. It takes a lot to upset me and I did feel very upset when I left the hospital that day because I just felt this is a regular screening for any woman and yet again a disability is stopping that from happening." A few months later Jane was diagnosed with stage 3 breast cancer which had spread to her lymph nodes. "That's when I started thinking if this had been picked up earlier maybe it wouldn't have spread," she said. Read full story Source: BBC News, 11 July 2024
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