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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
    This introductory course is aimed at those who are new to Human Factors or those who are interested in refreshing existing knowledge. You will gain the fundamental knowledge and skills for Human Factors in health and care. Taking place online over two half days, this course will blend guided independent study with facilitated discussion and activities. You will be encouraged to apply your learning to your own role and environment, to reduce error, improve processes that underpin patient safety, and support organisational safety culture. Learning objectives: Understand the basic concept of Human Factors. Understand the importance of Human Factors for safety and quality improvement. Have awareness of what influences human and system performance. Understand the basic concepts of systems thinking. Who is this for? This programme is ideal for any staff who wish to develop a basic knowledge/awareness of human factors. Register
  2. Event
    On this programme you will learn the benefits of taking an approach to measurement, focused specifically on improvement. You’ll discover a range of techniques to understand variation and measure change. This programme comprises of two modules, with an opportunity at the end to discuss your own measurement project. Our fast measurement start-up. You’ll learn about the different types of variation. You’ll be able to produce a Statistical Process Control (SPC) chart and understand what it’s telling you. In this session you will explore measurement in more depth, such as advanced SPC charts and confidence intervals, to help you dig into your data and turn it into intelligence you can act upon. Who is this for? Individuals who want to discover a range of techniques to understand variation and measure change. Register
  3. Content Article
    Nicholas Gerasimidis had a history of mental illness manifesting as obsessive compulsive disorder (OCD) and anxiety. In 2022, his condition deteriorated. His GP referred him twice to the Community Mental Health Team but the referrals were rejected with medication being prescribed instead, together with advice to contact Talking Therapies.   He was taken on to CMHT workload after being assessed by the Psychiatric Liaison Team in Royal Cornwall Hospital in November 2022. The preferred course of treatment was psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention. There was a waiting list of a year. In May 2023, Mr Gerasimidis became worse. It was felt an informal admission to hospital was required but a bed was not available. He was found hanged at his home address on 3 June 2023.
  4. Content Article
    Hospitals with high mortality and readmission rates for patients with heart failure (HF) might also perform poorly in other quality concepts. Wang et al. sought to evaluate the association between hospital performance on mortality and readmission with hospital performance rates of safety adverse events. They found that patients admitted with HF to hospitals with high 30-day all-cause mortality and readmission rates had a higher risk of in-hospital adverse events. There may be common quality issues among these 3 measure concepts in these hospitals that produce poor performance for patients with HF.
  5. News Article
    "Taking medication meant my brain was quiet for the first time; it was amazing, I cried because I was so happy," Jass Thethi, whose life was transformed after an ADHD diagnosis just over a year ago, told a BBC North West investigation. But the 34-year-old's joy was short-lived because, like more than 150,000 others who live with the condition and are reliant on medication, Jass has been affected by a UK-wide medicine shortage that started in September. Jass, who lives in Levenshulme, Greater Manchester, said: "When the medication shortage started I had to go back to white knuckling everyday life… I had to take the decision to change things and I had to quit the job I was doing." The charity ADHD UK said it had recorded a "significant decline" in the availability of medicines, with only 11% having their normal prescription in January, a drop from 52% in September. The Department of Health and Social Care (DHSC) said increased global demand and manufacturing issues were behind the shortages. Dr Morgan Toerien, associate specialist in mental health at Beyond Clinics in Warrington, said Jass's experience was not unique and many patients' lives had been "completely destabilised". Read full story Source: BBC News, 27 February 2024 Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy? To help us understand how these issues impact the lives of patients and families, please share your experience and insights in our Community post. We would also like to hear from pharmacists working in community or hospital settings, and others who have insights to share on this issue.
  6. News Article
    Major progress made in sepsis care during the previous decade has been significantly reversed amid repeated failures in recognising and treating the condition. HSJ has identified 31 deaths in the last five years where coroners have warned of systemic problems with diagnosing and treating sepsis, including nine cases relating to children. Many of the deaths were deemed avoidable. Meanwhile, investigations suggest a majority of acute trusts are failing to record their treatment rates for sepsis, which is deemed a crucial aspect of driving improvements. Repeated shortcomings raised by coroners, including 10 separate cases in 2023, include delays or failures to administer antibiotics, not following protocols for identifying sepsis, and inaccurate, missed or skipped observations. Health ombudsman Rob Behrens, who issued a report on sepsis failures last year, said the same mistakes were “clearly being repeated time and time again”. He added: “What is chilling to me is that these [coroners’ reports] fit in almost exactly with the issues we raised in our sepsis report… and even the 2013 sepsis report issued by my predecessor, including unnecessary delays, wrong diagnosis, and failure to provide adequate plans for sepsis.” Read full story (paywalled) Source: HSJ, 27 February 2024
  7. News Article
    Mothers of babies who died or suffered brain damage from a Group B Strep (GBS) infection say routine screening is needed. Oliver Plumb, from the charity Group B Strep Support, said it was a "small number of babies" exposed to the bacteria that developed a serious and potentially fatal infection. He said around 800 babies a year developed the infection - which is about two babies a day - and about one a week will die, while another a week will be left with a lifelong disability. "It's a heart-breaking start to life for families and that often the first they hear of Group B Strep is when their baby is sick or in intensive care". The charity has called for GBS to be a notifiable disease to make it a legal responsibility for infections to be reported. It added that current figures could be "missing around one fifth of the infections". There was a "postcode lottery" in terms of how many families will hear about GBS, he said. The charity also backed calls for screening. "In the UK we don't sadly have a routine testing programme, that's at odds with much of the rest of the high-income world. " A DHSC spokesperson said a public consultation on the notifiable diseases list was carried out last year. "DHSC and UKHSA are considering the responses and confirmation of any changes will be published in due course," they said. Several reasons for not recommending routine screening have been given by the committee, including that results can change in the last few weeks of labour, and that GBS does not cause infection in every baby. Read full story Source: BBC News, 26 February 2024 Further reading on the hub: Leading for safety: A conversation with Jane Plumb, Founder of Group B Strep Support
  8. News Article
    The number of people in the UK who have avoidant restrictive food intake disorder (Arfid), in which those afflicted avoid many foods, has risen sevenfold in five years, figures show. The eating disorders charity Beat received 295 calls about Arfid in 2018 – comprising 2% of its 20,535 inquiries that year. However, it received 2,054 calls last year, which accounted for one in 10 of its 20,535 requests for help. Many were from children and young people or their parents. Andrew Radford, Beat’s chief executive, said: “It’s extremely worrying that there has been such a dramatic increase in those seeking support for Arfid, particularly as specialist care isn’t always readily available.” Patchy provision of NHS help meant many people were experiencing long delays before accessing support, he added. Eight in 10 eating disorder service providers did not state on their website whether or not they offered Arfid care, research by Beat found. “All too often we hear from people who have been unable to get treatment close to home or have faced waits of months or even years to get the help they need,” Radford said. Arfid is much less well-known than anorexia or bulimia. It is “an eating disorder that rarely gets the attention it deserves”. The sharp increase in cases should prompt NHS chiefs to end the postcode lottery in care for Arfid and ensure that every region of England had a team of staff fully trained to treat it, he added. “Unlike other eating disorders such as anorexia or bulimia, Arfid isn’t driven by feelings around [someone’s] weight or shape,” Radford said. “Instead, it might be due to having sensory issues around the texture or taste of certain foods, fear about eating due to distressing experiences with food, for example choking, or lack of interest in eating.” Read full story Source: The Guardian, 26 February 2024
  9. News Article
    A newly installed electronic patient record contributed to the “preventable” death of a 31-year-old woman in an emergency department, a trust has been warned. Emily Harkleroad died at University Hospital of North Durham in December 2022 following “failures to provide [her] with appropriate and timely treatment” for a pulmonary embolism, a coroner has said. The inquest into her death heard emergency clinicians had raised concerns about a newly installed electronic patient record, provided by Oracle Cerner, which they said did not have an escalation function which could clearly and quickly identify the most critical patients. The inquest heard the new EPR, installed in October 2022, did not have a “RAG rating” system in which information on patient acuity “was easily identifiable by looking at a single page on a display screen” – as was the case with the previous IT system. The software instead relied on symbols next to patients’ names which indicate their level of acuity when clicked on, but did “not [provide] a clear indication at first glance” of their level of acuity. Rebecca Sutton, assistant coroner for County Durham and Darlington, said that “errors and delays” meant Ms Harkleroad did not receive the anticoagulant treatment that she needed and “which would, on a balance of probabilities, have prevented her death”. “It is my view that, especially in times of extreme pressure on the emergency department, a quick and clear way of identifying the most critically ill patients is an important tool that could prevent future deaths.” Read full story (paywalled) Source: HSJ, 23 February 2024
  10. Content Article
    On 18 December 2022, Emily Harkleroad collapsed when out with a friend. She was taken by ambulance to the University Hospital of North Durham Emergency Department. Despite staff recognising that pulmonary embolism was the likely diagnosis, there were failures to provide Emily with appropriate and timely treatment for pulmonary embolism. Errors and delays in the Emily’s medical treatment resulted in her not receiving the anticoagulant treatment that she needed, and which would, on a balance of probabilities, have prevented her death. She died as a result of pulmonary embolism in the early hours of 19 December 2022 at the University Hospital of North Durham.
  11. News Article
    Left in agonising pain, with staff ignoring his cries for help, Martin Wild called 999 from his hospital bed, desperate for someone to get him the medication he needed. This was just the beginning of the 73-year-old’s “nightmare” experience at the hands of Salford Royal Hospital. Over nearly five months, the former car salesman says he was subjected to prolonged periods of neglect, including being left to lie in urine-soaked sheets, pleading for medication. He lost so much weight that, according to his wife, he became skin and bone. One staff member involved in his care said they’d never seen a hospital patient neglected to such a serious degree. Mr Wild told The Independent that his time at Salford Royal Hospital has shattered his belief in the NHS and that he believes it is not fit for purpose. “It was a nightmare in that ward. I didn’t feel like there was much caring going on,” he said. “I used to lie there at night; I could hear people shouting and screaming for help. It was like being in the third world.” Read full story Source: The Independent, 24 February 2024
  12. News Article
    The House of Lords is being urged to throw out plans for non-doctor associate roles to be licensed by the same body as doctors. Under a planned new law, physician associates (PAs) will be regulated by the General Medical Council (GMC). The British Medical Association (BMA) believes this could lead to patients confusing the different roles, which it says could have "tragic consequences". There are about 3,200 PAs working in GP surgeries and hospitals in England, with 10,000 more planned in the next decade or so. They were introduced to help doctors with their work - examining and diagnosing patients and discussing treatments with them - although PAs are currently unregulated. Unlike doctors, they do not have to hold a medical degree, but they usually have a degree in a life science and have to undertake a two-year training course. The BMA, the union representing doctors in the UK, believes that regulation by the GMC could lead to a "blurring of the lines" between PAs and doctors. In an open letter to the House of Lords ahead of a debate on Monday, the BMA's chairman Prof Phil Banfield said: "PAs are not doctors. They do not hold a medical degree and are not medically trained, despite misleading statements made by some. "We know that patients are already confused about telling the difference between PAs and doctors, and this legislation will make this problem worse. "Keeping the GMC as the regulator exclusively of doctors would mean we retain the clear distinction between doctors and PAs." Read full story Source: BBC News, 25 February 2024
  13. Content Article
    Ombudsman, Rob Behrens and Patient Safety Commissioner, Henrietta Hughes, have written a letter to the Government sharing their joint concerns regarding what they see as the confrontational culture created by the complaints process in some areas of the NHS that undermines patient safety. 
  14. Content Article
    Wellcome Collection long read on two women who battled through decades of medical paternalism: Marie Lyon, who took Primodos, and Dr Isabel Gal, the scientist who first raised the alarm.
  15. Content Article
    Continuity of care, defined as an ongoing therapeutic relationship between a patient and a physician, is a defining characteristic of primary care. However, arranging a consultation with one’s regular doctor is increasingly difficult as practices face physician shortages. Kajaria-Montag et al. studied the effect of declining care continuity on the productivity of physicians by analysing data of over 10 million consultations in 381 English primary care practices over a period of 11 years. Specifically, they examined whether a consultation with the patient’s regular doctor is more productive than with another doctor in the practice. The authors found that the time to a patient’s next visit is on average 18.1% longer when the patient sees the doctor they have seen most frequently over the past two years, while there is no operationally meaningful difference in consultation duration. The data show that the productivity benefit of care continuity is larger for older patients, patients with multiple chronic conditions, and patients with mental health conditions. The authors estimate that the total consultation demand in their sample could have fallen by up to 5.2% had all practices offered continuity of care at the level of the top decile of practices while prioritising patients expected to yield the largest productivity benefits.
  16. News Article
    Seeing the same GP improves patients’ health, reduces doctors’ workloads and could free up millions of appointments, according to the largest study of its kind. Research has previously suggested there may be benefits to seeing the same family doctor. But studies have mostly been small or covered a short period of time. Now University of Cambridge and Insead business school researchers have analysed data from 10m consultations over more than a decade in the most authoritative study on the issue yet. They found that if all GP practices moved to a model where patients saw the same doctor at each visit, it would significantly reduce doctors’ workloads while improving patient health. Multiple benefits emerged when patients had a long-term relationship with their doctor, researchers found. Seeing the same GP – known as continuity of care – meant people waited on average 18% longer between visits, compared with patients who saw different doctors. People did not take up more GP time in each consultation and the findings were particularly strong for older patients, those with multiple chronic illnesses, and people with mental health conditions. Although it will not always be possible for people to see their regular GP, researchers said the findings would translate to an estimated 5% reduction in consultations if all practices provided the level of continuity of care of the best 10% of practices. That suggests millions of appointments could be freed up. The researchers added: “Importantly, if patients receiving care from their regular doctors have longer intervals between consultations without requiring longer consultations, then continuity of care can potentially allow physicians to expand their patient list without increasing their time commitment.” Read full story Source: The Guardian, 23 February 2024
  17. News Article
    Black children in the UK are four times more likely to experience complications after appendicitis surgery than their white counterparts, a study has found. The study, funded by the Association of Paediatric Anaesthetists of Great Britain and Ireland, looked at 2,799 children from 80 hospitals across the UK aged under 16 who had surgery for suspected appendicitis between November 2019 and January 2022. Of these, 185 children (7%) developed postoperative complications within 30 days of the surgery. Three-quarters of these complications were related to the wound, while a quarter were respiratory, urinary or catheter-related or of unknown origin. The study found that black children had a four times greater risk of experiencing complications after the operation, and that this risk was independent of the child’s socioeconomic status and health history. Appendicitis is one of the most common paediatric surgical emergency with 10,000 performed every year. The authors said that this was the first study to look at the demographic differences of postoperative complication rates in regards to appendicitis. The researchers said they could not draw firm conclusions regarding why black children had worse outcomes after this type of emergency surgery, and that this apparent health inequality “requires urgent further investigation and development of interventions aimed at resolution”. Read full story Source: The Guardian, 22 February 2024
  18. Content Article
    The Scottish Government needs to develop a clear national strategy for health and social care to address the pressures on services, says a review by Audit Scotland. Significant changes are needed to ensure the financial sustainability of Scotland's health service. Growing demand, operational challenges and increasing costs have added to the financial pressures the NHS was already facing. Its longer-term affordability is at risk without reform.
  19. News Article
    Scotland's NHS is unable to meet the growing demand for health services, a spending watchdog has warned. A review by Audit Scotland said the increased pressure on the NHS was now having a direct impact on patient safety and experience. The watchdog also claimed there was no "overall vision" for the future of the health service. The annual report on the state of Scotland's health service highlighted that the NHS was facing soaring costs, patients were waiting longer to be seen and there were not enough staff. Stephen Boyle, Auditor General for Scotland, said this had "added to the financial pressures on the NHS and, without reform, its longer-term affordability". He added: "Without change, there is a risk Scotland's NHS will take up an ever-growing chunk of the Scottish budget. And that means less money for other vital public services. "To deliver effective reform the Scottish government needs to lead on the development of a clear national strategy for health and social care. "It should include investment in measures that address the causes of ill-health, reducing long-term demand on the NHS." Read full story Source: BBC News, 22 February 2024
  20. News Article
    Bereaved parents who lose a baby before 24 weeks of pregnancy in England can now receive a certificate in recognition of their loss. Ministers say they have listened to bereaved parents who have gone through the painful experience of miscarriage. Campaigners said they were "thrilled" that millions of families would finally get the formal acknowledgement that their baby existed. All parents who have experienced baby loss since September 2018 can apply. They should visit the gov.uk website - applicants must be at least 16 years old, have been living in England at the time of the loss and be one of the baby's parents or surrogate. In Wales, there are plans to deliver a similar scheme. Babies who are born dead after 24 completed weeks of pregnancy are called stillbirths, and their deaths are officially registered. But this does not happen for babies who die before that stage. Pregnancy loss or miscarriage before 24 weeks is the most common complication of pregnancy, experienced by an estimated one in five women in the UK. Read full story Source: BBC News, 21 February 2024
  21. Content Article
    The King's Fund 'Mental health 360' aims to provide a ‘360-degree’ review of mental health care in England. It focuses on nine core areas, bringing together data available at the time of publication with expert insights to help you understand what is happening in relation to mental health and the wider context. The nine core areas covered are: Prevalence Access Workforce Funding and costs Quality and patient experience Acute mental health care for adults  Services for children and young people Inequalities Data.
  22. News Article
    Health secretary Victoria Atkins has said mental health patients and staff must report the “horrific” sexual abuse allegations uncovered by The Independent to the police. Ms Atkins said victims would have her full support if they reported their claims to the police. Her intervention comes following a joint investigation by The Independent and Sky News, which revealed almost 20,000 reports of sexual harassment and abuse on NHS mental health wards in England. The allegations uncovered include patients claiming to have been raped by staff and other patients while being treated on mental health wards. In response to the initial investigation, Ms Atkins said a review launched last year into mental health services would now also look into sexual assault within the sector. Speaking on Sky News, she said: “These are horrific allegations that should not and must not happen in our care. Very, very vulnerable people have to stay in mental health inpatient facilities, and they do so because they need care, support, and treatment. “Some of the behaviours that have come to light are criminal offences, and so I would encourage anyone who feels able to – and I appreciate it is a difficult step – to go to the police and please report them, because they are crimes and we must drive them out.” Read full story Source: The Independent, 21 February 2024
  23. News Article
    From forgetfulness to difficulties concentrating, many people who have Long Covid experience “brain fog”. Now researchers say the symptom could be down to the blood-brain barrier becoming leaky. The barrier controls which substances or materials enter and exit the brain. “It’s all about regulating a balance of material in blood compared to brain,” said Prof Matthew Campbell, co-author of the research at Trinity College Dublin. “If that is off balance then it can drive changes in neural function and if this happens in brain regions that allow for memory consolidation/storage then it can wreak havoc.” Writing in the journal Nature Neuroscience, Campbell and colleagues report how they analysed serum and plasma samples from 76 patients who were hospitalised with Covid in March or April 2020, as well 25 people before the pandemic. Among other findings, the team discovered that samples from the 14 Covid patients who self-reported brain fog contained higher levels of a protein called S100β than those from Covid patients without this symptom, or people who had not had Covid. This protein is produced by cells within the brain, and is not normally found in the blood, suggesting these patients had a breakdown of the blood-brain barrier. Read full story Source: The Guardian, 22 February 2024
  24. Content Article
    When public areas such as train stations breach their capacity, emergency protocols are rolled out and stations are closed. Yet when hospitals become overcrowded, there isn’t the option to stop urgent and emergency care. Instead, staff have to develop workarounds, delivering care in areas not designed – nor safe or effective – for clinical use, a phenomenon commonly known as ‘corridor care’. The increasing frequency of corridor care is alarming – both for patient safety and staff morale, and because it risks normalising substandard care delivery.  Corridor care largely occurs when emergency departments are inundated with patients. 45,000 people visit major hospital A&E departments in England each day, 16% more than 10 years ago. Many of these patients require hospital admission or further care. Limited beds within hospitals, stretched community services and chronically low social care capacity mean that A&E often becomes a bottleneck, with patients unable to ‘flow’ out of the department because there are no free beds elsewhere in the hospital. In this blog, Heather Wilson a Programme and Policy Officer in the Healthy Lives team at the Health Foundation, as well as a registered nurse who continues to work in a central London emergency department discusses the impact of corridor care on staff, patients and families. Further reading on the hub: A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift
  25. Event
    until
    Today, the entire world is working together to address one of history's most terrible public health issues. Humanity has been defeated by a virus and is attempting to restore regular functions while protecting its safety and health. Several tactics and policies have evolved as means of reducing the pandemic's spread and effects, and several are being tested and developed. The information and expertise contained within the field of Public Health are critical in this regard and are regularly revised and updated in the current circumstances. Among the various components of Public Health, Public Health Interventions have become increasingly used in altering public behaviour as a means of limiting disease spread. As a result, the Global Conference on Public Health 2024 (Hybrid Conference) anticipates analysing and evaluating the capabilities of Public Health Interventions in managing the pandemic with the assistance of scholars and specialists in this field. Register
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