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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Serious failings in support for deaf children have been laid bare in the final report of the Independent Review of Audiology Services in Scotland. Mark Ballard, National Deaf Children's Society, Head of Policy for Scotland, outlines the history of the Review, and suggests that it is time for the Scottish Government to act on the recommendations of the report.
  2. Content Article
    Review report and recommendations from the Independent Review of Audiology Services in NHS Scotland. The Review was announced by the Scottish Government in January 2022 in the context of failings in the standards of care provided in the NHS Lothian Paediatrics Services.
  3. News Article
    NHS patients raising safety concerns are too often “gaslighted”, “fobbed off” or dismissed as “difficult women”, according to England’s patient safety commissioner, who criticised health leaders for a “relentless focus” on finance and productivity. Dr Henrietta Hughes said patients and loved ones sounding the alarm about substandard care should be an early indicator of danger or potential harm, but far too frequently they were completely ignored. NHS trusts focusing too much on budgets meant that “the culture becomes toxic, and we’re just on the road back to the Mid Staffs scandal”, she added. Hughes was referring to the failures at Mid Staffordshire NHS foundation trust, where hundreds of patients were neglected, dismissed or ignored between 2005 and 2009. Some were left lying in their own urine, unable to eat, drink or take essential medication. “The patient’s anecdote is the canary in the coalmine,” she said. “It’s the thing that tells us there’s something going wrong. But too often we hear about patients who have raised concerns being gaslighted, dismissed, and fobbed off.” Read full story Source: The Guardian, 10 July 2024
  4. Content Article
    When thinking about the difference patients can make in improving care, Patient Safety Commissioner Henrietta Hughes recalls a recent visit to a stroke unit. “One of the patients said, ‘In the toilets, it would be much better if you had toilet paper on both sides of the cubicle, because if you’ve had a stroke you’ve only got a 50% chance of being able to reach it,’” she says. “Now, the power of that story is that you can have a unit full of experts—clinical nurse specialists, professors, people with PhDs—and they know everything about stroke, but they’ve never been in a cubicle with a patient who’s had a stroke when they’re on the toilet.” For Hughes, that one moment crystallises the kind of insight that only a patient can bring. However, evidence that NHS patients often aren’t listened to keeps on coming. “The patient’s anecdote is the canary in the coal mine,” tells Hughes to the BMJ. “It’s the thing that tells us there’s something going wrong. But too often we hear about patients who have raised concerns being gaslighted, dismissed, and fobbed off.”
  5. News Article
    A small number of biomedical scientists are being investigated following fitness to practise concerns relating to cervical screening in the Southern Trust, BBC News NI understands. In October 2023, it emerged smear tests of more than 17,000 women in the trust would be re-checked as part of a review dating back to 2008. It is understood that some of the women affected have since referred the matter to the Health and Care Professions Council (HCPC) which investigates concerns about the practice of a professional on its register. Stella McLoughlin from Newry, who is one of the 17,500 women affected by the re-check, said the review process has left her feeling “very afraid, fragile, and angry”. Following news that other women in her position have referred the matter to the HCPC, she said there needs to be an investigation. "I don't know why they're calling it a review because to me this is a scandal. This has affected so many women," she said. Read full story Source: BBC News, 11 July 2024
  6. News Article
    An independent investigation will be held into the performance of the NHS, the health secretary has announced. Writing in the Sun, Wes Streeting said the investigation would be aimed at “diagnosing the problem” so the government could “write the prescription”. Streeting said: “It’s clear to anyone who works in or uses the NHS that it is broken. Unlike the last government, we are not looking for excuses. I am certainly not going to blame NHS staff, who bust a gut for their patients. “This government is going to be honest about the challenges facing us, and serious about solving them.” Streeting said the investigation would be led by the former health minister Lord Ara Darzi, who he has asked to “tell hard truths”. Streeting said: “Honesty is the best policy, and this report will provide patients, staff and myself with a full and frank assessment of the state of the NHS, warts and all. “The NHS has been wrecked. This investigation will be the survey, before we draw up plans to rebuild it anew, so it can be there for all of us when we need it, once again.” Read full story Source: The Guardian, 11 July 2024
  7. News Article
    The vast majority of eye doctors believe increased outsourcing of cataract operations to private clinics in England in recent years has negatively affected their NHS departments, research has found. Almost three-quarters of ophthalmologists surveyed said that outsourcing of cataracts to the private sector had a negative impact on their NHS eye care departments, with 54% flagging a large negative impact and 16% a small one. The survey of 200 eye doctors by the Centre for Health and the Public Interest (CHPI), shared with the Guardian, came after Wes Streeting, the new health secretary, pledged to divert billions of pounds from hospitals to GPs to “fix the front door to the NHS” and met junior doctors on Tuesday to try to end a long-running pay dispute. Nearly 60% of the ophthalmologists polled said outsourcing had a negative impact on NHS staffing, 62% said the same for staff training, and 46% said it harmed the ability of public eye care departments to treat patients with more complex conditions. Issues raised about staffing included the loss of consultants, nurses and optometrists to the private sector. While eye care budgets have increased by only 15% at 43 NHS trusts over the past five years, ophthalmology spending has gone up by 52%, partly due to a surge in the number of cataract operations, research from the CHPI showed. Hundreds of thousands more NHS patients a year are having cataracts removed in England in a boom driven by private clinics but funded by taxpayers. Read full story Source: The Guardian, 10 July 2024
  8. Content Article
    The role of patients in the design and assessment of products is increasingly becoming important for product approval. At the June Health Tech Alliance member Meeting, Clive Flashman and Rachel Power presented on engaging patients in digital health innovation. Below is a summary of their presentation and Q&As after.
  9. News Article
    Fourteen never events recorded at University Hospitals Birmingham Foundation Trust’s transfusion service were the “tip of an iceberg”, an external review has concluded. The Royal College of Physicians (RCP) investigation, obtained by HSJ, reveals the service saw more than 150 additional “adverse events” recorded in just three months. The review of the service’s activities between 2019 and early 2023 also concluded there had been “inaction” at senior management level on addressing the problems and that there was a lack of understanding among senior leaders about the significance of the risks posed by the service. The RCP report said it was unlikely the reviewed never events “comprised the totality” of transfusion errors by the service and concluded that they were in fact just the “tip of an iceberg” of the errors made by the service. These included seven incidents of the wrong blood being stored in tubes and a patient “with childbearing potential” incorrectly transfused in accident and emergency with group O RhD positive blood. This risks the patient’s antibodies attacking a future unborn baby if the foetus is RhD positive. ABO-incompatible blood transfusions have a potential for significant morbidity and mortality and are “wholly preventable”, according to NHS Blood and Transplant. Read full story (paywalled) Source: HSJ, 10 July 2024
  10. News Article
    Tens of thousands of patients are still suffering harm from delays in ambulance handovers to emergency departments despite a concerted effort to tackle the problem, figures seen by HSJ indicate. The data shows more hours have been lost to handover delays lasting more than 15 minutes in most of the first five months of 2024 compared to the same period in 2023. In May, more hours were lost than in May 2022 and May 2023. The Association of Ambulance Chief Executives told HSJ the problem remained severe and the government needed to act to improve it. AACE managing director Anna Parry said it had consistently warned about the ongoing risk of handover delays. She said: “This is why one of our key requests of the new government has been that they proactively support the ambulance sector’s aim to ensure patients universally receive high-quality, timely care and no longer experience unacceptable delays in response or handover of care, for example, at hospital emergency departments. “This problem is not intractable. We have demonstrated that in areas where there is a strong leadership focus and true system-wide support, handovers can be managed effectively, despite the significant pressures and constraints our health and social care system is under. However, it remains vital that we see more demonstrations of excellent leadership to get to that point across the country.” Read full story (paywalled) Source: HSJ, 10 July 2024
  11. Content Article
    How is it possible to ensure that NHS Trusts learn from their mistakes? In this blog, Trevor Stevens, member of Making Families Count, explains how he intends to go about it. 
  12. Content Article
    The aim of the study was to describe the experiences related to sleep and night time rest of patients hospitalised in the intensive care unit (ICU). The study used a qualitative project based on phenomenology as a research method. A semi-structured interview was used as the method to achieve the goal. The patients’ answers were recorded and transcribed. The data were coded and cross-processed. Five themes were identified from the interview as factors disturbing sleep: fear, noise, light, medical staff, and at home best. Chronic anxiety appears to contribute to sleep disturbances in the ICUs, psychological support, and individualised approach to the hospitalised patient seem necessary. By raising the awareness of the essence of sleep among medical staff, environmental factors can be reduced as disturbing sleep. Based on the participants’ comments, it is possible that repeated actions could also increase the patients’ sense of security.
  13. Content Article
    The need for sleep has long been assumed to be important for recovery from injury and sickness, and there is an emerging understanding of the restorative role of sleep in health and disease. Unfortunately, the hospital environment is often poorly conducive to sleep. Pain, anxiety, medication effects, medical interventions, environmental noise and light, and the acute illness itself all contribute to decreased quality and quantity of sleep in hospitalised patients. As a result, issues related to sleep and sleep disorders are important to inpatient care. This review will discuss the evaluation, consequences, and management of sleep disturbances in hospitalised adult patients.
  14. Content Article
    Current levels of inactivity on CQC’s part risks a range of detrimental impacts on service users, staff, operators and investors across the health and social care sector writes Carlton Sadler.
  15. Content Article
    What is social care? How many people deliver social care? How much does social care cost individuals and the state? The King's Fund answers some key questions on social care that have been frequently or recently posed to them.
  16. News Article
    Ministers will divert billions of pounds from hospitals to GPs to “fix the front door to the NHS”, Wes Streeting has promised as he said millions of patients will be able to see the same family doctor at every appointment. The health secretary made his first major policy announcement as he prepared to begin vital talks with junior doctors on Tuesday, aimed at finally ending the strikes that have crippled the health service since 2022. Less than 10% of the £165bn NHS budget in England is spent on primary care, and that share has been falling, despite record high demand at GP surgeries. In a significant policy shift, Streeting on Monday said he would reverse that trend and boost the proportion of the budget for primary care so patients could access help sooner. More than 5 million patients a month in England are waiting longer than a fortnight for a GP appointment after the previous government promised everyone would be able to get one within 14 days. After visiting Abbey Medical Centre, a GP surgery in St John’s Wood, London, Streeting said: “Patients are finding it harder than ever to see a GP. Patients can’t get through the front door of the NHS, so they aren’t getting the timely care they need. “That’s no surprise, when GPs and primary care have been receiving a smaller proportion of NHS resources. I’m committed to reversing that.” Read full story Source: The Guardian, 8 July 2024
  17. News Article
    The NHS must concentrate on the basics of cancer treatment rather than the “magic bullets” of novel technologies and artificial intelligence, or risk the health of thousands of patients, experts have warned. In a paper published in the journal Lancet Oncology, nine leading cancer doctors and academics say the NHS is at a tipping point in cancer care with survival rates lagging behind many other developed countries. The NHS has not met its target for 85% of cancer patients to start treatment within two months since December 2015. International research shows that every four weeks of delay in treatment increases the risk of death by up to 10%. It means hundreds of thousands of people have to wait months to start essential cancer treatment, and only 67% begin treatment within 62 days. The paper highlights 10 pressure points that are contributing to entrenched cancer survival inequalities, diagnosis and treatment delays, and inappropriate care. In a sharply worded warning, the cancer experts say “novel solutions” such as new diagnostic tests have been wrongly hyped as “magic bullets” for the cancer crisis, but “none address the fundamental issues of cancer as a systems problem”. Read full story Source: The Guardian, 8 July 2024
  18. Content Article
    This policy review published in the Lancet Oncology discusses ten key pressure points in the NHS in the delivery of cancer care services that need to be urgently addressed by a comprehensive national cancer control plan. These pressure points cover areas such as increasing workforce capacity and its productivity, delivering effective cancer survivorship services, addressing variation in quality, fixing the reimbursement system for cancer care, and balancing of the cancer research agenda. These areas have been selected based on their relative importance to ensuring sustainable cancer services, persistence as key issues in the NHS, and their impact on delivering better and more equitable and affordable patient outcomes. Many of these pressure points are not acknowledged explicitly in any current discourse. The evidence provides points to their impact on the ability to deliver world class cancer care, but also to their amenability to affordable solutions if given the relevant prioritisation and investment. The current narrative needs to move away from a technocentric approach to improving care, to one focused on understanding the complexity of cancer services and the wider health system to drive improvements in survival, quality of life, and experience for patients.
  19. News Article
    The daughter of an elderly care home resident who suffered 32 falls in only 11 months said she had sent social services "a begging email" to warn her mother "was going to die" unless urgent improvements were made. "She suffered neglect in every way - it was devastating to see," said Kylie Gobin, whose mother Winifred Tubb lived at St Luke's in Runcorn, Cheshire. Mrs Gobin spoke to the BBC as part of an in-depth investigation which found nearly one in five care homes across England were rated as either "requiring improvement" or "inadequate". A spokesman for Halton Borough Council, which operates St Luke's, said it had "fully investigated" the complaints and "some lessons have been learnt". BBC England's data journalism team analysed Care Quality Commission (CQC) statistics and found the regulator now regards more than 2,500 care homes across England as "requiring improvement". The number of "inadequate" homes stands at 194 across England, but this figure is down on both 2022 and 2023. Read full story Source: BBC News, 9 July 2024
  20. News Article
    A “dysfunctional” culture at the UK nursing regulator is threatening public safety, according to a damning report that found the Nursing and Midwifery Council (NMC) took seven years to strike off a nurse who had been accused of rape and sexual assault. Staff at the regulator broke down in tears “as they recounted their frustrations over safeguarding decisions that put the public at risk”, according to the authors of an independent review of the regulator. The review team highlighted a “toxic culture” at the NMC, with one former employee describing their section of the organisation as a “hotbed of bullying, racism and toxic behaviour”. The report also shone a spotlight on suicides by nurses caught up in long drawn-out fitness to practise investigations, highlighting how some nurses had been under investigation for nearly 10 years. The authors commented on the NMC’s backlog of 6,000 cases, which meant some nurses were forced to wait four or five years for their investigation to be completed, even though some cases were “baseless complaints where no further action is required”. Read more Source: The Guardian, 9 July 2024
  21. Content Article
    An independent review of the Nursing and Midwifery Council (NMC)'s culture has highlighted safeguarding concerns, and found that people working in the organisation have experienced racism, discrimination and bullying. We take this extremely seriously and will deliver a culture change programme rooted in the review’s recommendations. The NMC commissioned Nazir Afzal OBE and Rise Associates to carry out the review after concerns were raised about the organisation’s culture, including racism and fear of speaking up. Over 1,000 current and former NMC colleagues, plus more than 200 panel members who sit on fitness to practise hearings, shared their lived experiences as part of the review. The NMC accepts the report’s recommendations.
  22. News Article
    Former nurse Lucy Letby has been sentenced to another whole life term for trying to kill a premature baby girl. The 34-year-old is already in jail for murdering seven babies and attempting to murder six others at the Countess of Chester Hospital between June 2015 and June 2016. On Tuesday, she was found guilty of trying to murder another girl, known as Baby K, following a retrial. Letby had refused to go up to the dock to be sentenced to 14 whole life terms last August, but was in the dock earlier to be handed her 15th. Her original murder trial jury acquitted her of two counts of attempted murder, and there were six further charges on which jurors could not decide, including that concerning Baby K. Read full story Source: BBC News, 5 July 2024
  23. Content Article
    The UK, like many other countries, has developed occupations intended to alleviate the work of nurses. Variously called nursing assistants or associates, there are now over 10 000 registered in the UK. Unfortunately, the evidence on patient safety is far from reassuring. Experience with nursing assistants calls for extreme caution, write Rachel Greenley and Martin McKee in this BMJ opinion piece.
  24. Content Article
    This report examines the financial challenge facing NHS organisations in 2024/25.
  25. Content Article
    Patient safety challenges are exacerbated by healthcare workforce challenges. However, a workplace culture focused on measuring what goes wrong and making changes to address root causes – powered by reporting and analytics technology and encouraged by the example set by top leadership – can address these significant forces impacting care delivery.  Today’s healthcare environment demands effective digital tools and a commitment to cultural change, according to Heidi Raines, founder and CEO of Performance Health Partners, a healthcare safety software vendor.  Healthcare IT News spoke with Raines about near-miss reporting, and how better analytics and a culture of data-driven leadership can improve patient safety.
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