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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    An integrated care board (ICB) has found its handling of whistleblowing “not fit for purpose”, after a complaint about safety incidents not being properly investigated. A report by North West London ICB, obtained by HSJ, states: “The whistleblowing policy is not fit for purpose and requires immediate updating. The [Freedom to Speak Up] Guardian has been left blank and the policy does not include key components of best practice.” It also found the “whistleblower should have been provided with a substantive response to their concerns within 28 days” but in fact waited 98 working days, “due to delays with starting the whistleblowing component of the grievance”. The ICB reviewed its processes after a complaint from a staff member who raised concerns early last year about “a lack of, or poor, response” to reported patient safety incidents in the system, which are meant to be routinely reviewed by ICBs “prior to closure”. Read full story (paywalled) Source: HSJ, 15 February 2024
  2. News Article
    The number of patients waiting more than 12 hours for a bed on a ward after being seen in A&E in England was 19 times higher this winter than it was before the pandemic, figures show. There were nearly 100,000 12-hour waits in December and January - compared with slightly more than 5,000 in 2019-20. A decade ago these waits were virtually unheard of - in the four winters up to 2013-14 there were fewer than 100. The King's Fund said long delays were at risk of becoming normalised. It said the pressures this winter had received little attention compared with last winter, despite no significant improvement in performance. During December 2023 and January 2024, 98,300 patients waited more than 12 hours for a bed on a ward after A&E doctors took the decision to admit them. The Northern Ireland branch of the Royal College of Emergency Medicine (RCEM) said the pressures were "unsurmountable" and it was having a detrimental impact on patients. Read full story Source: BBC News, 15 February 2024
  3. News Article
    "Cultural and ethnic bias" delayed diagnosing and treating a pregnant black woman before her death in hospital, an investigation found. The probe was launched when the 31-year-old Liverpool Women's Hospital patient died on 16 March, 2023. Investigators from the national body the Maternity and Newborn Safety Investigations (MSNI) were called in after the woman died. A report prepared for the hospital's board said that the MSNI had concluded that "ethnicity and health inequalities impacted on the care provided to the patient, suggesting that an unconscious cultural bias delayed the timing of diagnosis and response to her clinical deterioration". "This was evident in discussions with staff involved in the direct care of the patient". The hospital's response to the report also said: "The approach presented by some staff, and information gathered from staff interviews, gives the impression that cultural bias and stereotyping may sometimes go unchallenged and be perceived as culturally acceptable within the Trust." Liverpool Riverside Labour MP Kim Johnson said it was "deeply troubling" that "the colour of a mother's skin still has a significant impact on her own and her baby's health outcomes". Read full story Source: BBC News, 16 February 2024
  4. Content Article
    A forthcoming three-part ITV drama Breathtaking, set in a fictionalised London hospital, tells the devastating impact of the Covid-19 pandemic through the eyes of Acute Medical Consultant Dr Abbey Henderson. The series is based on Dr Rachel Clarke’s book of the same name. She worked on Covid wards and is also one of the writers on the series. Rachel joins Women's Health host Emma Barnett to discuss it. Listen from 1:40
  5. Content Article
    In December 2022, a newly formed group called 'Long Covid Doctors for Action' (LCD4A) conducted a survey to establish the impact of Long Covid on doctors. When the British Medical Association published the results of the survey, the findings were both astonishing and saddening in equal measure.[1] The LCD4A have now decided that enough is enough and that it is now time to stand up and take positive action. They have initiated a group litigation against those who failed to exercise the ‘duty of care’ that they owed to healthcare workers across the UK during the pandemic.  In this blog, I summarise how and why I feel our healthcare workers have been let down by our government and why, if you are one of these healthcare workers whose life has been effected by Long Covid, I urge you to join the group litigation initiative.
  6. Content Article
    An action-oriented and radically hopeful field guide to the underground, patient-led revolution for better health and healthcare. Anyone who has fallen off the conveyer belt of mainstream health care and into the shadowy corners of illness knows what a dark place it is to land. Where is the infrastructure, the information, the guidance? What should you do next? In Rebel Health, Susannah Fox draws on twenty years of tracking the expert networks of patients, survivors, and caregivers who have come of age between the cracks of the health care system to offer a way forward. Covering everything from diabetes to ALS to Moebius Syndrome to chronic disease management, Fox taps into the wisdom of these individuals, learns their ways, and fuels the rebel alliance that is building up our collective capacity for better health. Rebel Health shows how the next wave of health innovation will come from the front lines of this patient-led revolution. Fox identifies and describes four archetypes of this revolution: seekers, networkers, solvers, and champions. Each chapter includes tips, such as picking a proxy to help you navigate the relevant online communities, or learning how to pitch new ideas to investors and partners or new treatments to the FDA. On a personal level, anyone who wants to navigate the health care maze faster will want to become a health rebel or recruit some to their team. On a systemic level, it is a competitive advantage for businesses, governments, and organizations to understand and leverage the power of connection among patients, survivors, and caregivers.
  7. Content Article
    Medication errors in ambulatory care settings present unique patient safety challenges. This systematic review explored the prevalence of medication errors in outpatient and ambulatory care settings. Findings indicate that prescribing errors (e.g., dosing errors) are the most common type of medication error and are often attributed to latent factors, such as knowledge gaps.
  8. News Article
    A Mississippi prison denied medical treatment to an incarcerated woman with breast cancer, allowing her condition to go undiagnosed for years until it spread to other parts of her body and became terminal, according to a lawsuit filed on Wednesday. Susie Balfour, 62, alleges that Mississippi department of corrections (MDOC) medical officials were aware she might have cancer as early as May 2018, but did not conduct a biopsy until November 2021, one month before she was released from prison. It was not until January 2022, after she left an MDOC facility, that a University of Mississippi Medical Center doctor diagnosed her with stage four breast cancer, according to her federal complaint. Her lawsuit and medical records paint a picture of a prison healthcare system that deliberately delayed life-saving healthcare and for years repeatedly failed to conduct follow-up appointments that the MDOC’s contracted clinicians recommended. Read full story Source: The Guardian, 14 February 2024
  9. Content Article
    A swarm is designed to start as soon as possible after a patient safety incident occurs. Healthcare organisations in the US1 and UK2 have used swarm-based huddles to identify learning from patient safety incidents. Immediately after an incident, staff ‘swarm’ to the site to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning. They can prevent: those affected forgetting key information because there is a time delay before their perspective on what happened is sought fear, gossip and blame; by providing an opportunity to remind those involved that the aim following an incident is learning and improvement information about what happened and ‘work as done’ being lost because those affected leave the organisation where the incident occurred. This swarm tool provided by NHS England integrates the SEIPS3 framework and swarm approach to explore in a post-incident huddle what happened and how it happened in the context of how care was being delivered in the real world (ie work as done). 
  10. Content Article
    The recent Hughes Report outlined the options for redress for those harmed by valproate and pelvic mesh  In this blog, AvMa's Chief Executive, Paul Whiteing, discusses the trade-off of redress schemes.
  11. News Article
    The doctor in charge of medical training for NHS England has apologised unreservedly to the family of a medic who took her own life. Dr Vaish Kumar, a junior doctor, left a suicide note blaming her death entirely on the hospital where she worked, her family revealed last year. Dr Kumar, 35, was wrongly told she needed to do a further six months of training before starting a new role. It meant she was forced to stay at Queen Elizabeth Hospital (QE) in Birmingham, where she had been belittled by colleagues, an inquest heard. In a letter to Dr Kumar's family, seen by the BBC, NHS bosses admitted she did not need to do the extra training. Dr Navina Evans, chief workforce and training education officer for England, told the family in the letter: "I wish to unreservedly apologise for these mistakes and for the impact they would have had. "As an organisation we are determined to learn... not only across the Midlands but across England as a whole." Read full story Source: BBC News, 13 February 2024
  12. News Article
    A woman who described the time in her life after a pelvic mesh implant as "soul destroying" said proposed government compensation was "disappointingly low". Claire Cooper, from Uckfield, is one of around 100,000 women across the UK who had transvaginal mesh implants. England's patient safety commissioner suggested compensation could start at around £20,000. Ms Cooper, 49, was originally given the mesh implant as a treatment for incontinence after childbirth. However, after struggling with pain following the operation, Ms Cooper claimed doctors treated her as if she were "psychotic" and "a nuisance". She said her experience was one of being "mocked". "It was just soul destroying," Ms Cooper told BBC Radio Sussex. "I lost my fight because I was met at every turn with resistance so I just lost the ability to advocate for myself." Ms Cooper eventually had surgery to remove the mesh, which she said one doctor compared to "cheese cutting wire". She is still living with chronic pain. Read full story Source: BBC News, 15 February 2024 Further reading on the hub: Doctors shocking comments to women harmed by mesh
  13. News Article
    More than 100 patients who had eggs and embryos frozen at a leading clinic have been told they may have been damaged due to a fault in the freezing process. The clinic, at Guy's Hospital in London, said it may have unwittingly used some bottles of a faulty freezing solution in September and October 2022. But it said it did not know the liquid was defective at the time. One patient at a second clinic, Jessop Fertility in Sheffield, has also been affected, the BBC has learned. The fertility industry regulator, the Human Fertilisation and Embryology Authority (HFEA), said it believes the faulty batch was only distributed to those two clinics. It is believed that many of the patients affected have subsequently had cancer treatment since having their eggs or embryos frozen, which may have left them infertile. This means they now may not be able to conceive with their own eggs. Guy's Hospital's Assisted Conception Unit is now being investigated by the HFEA, because of a delay in informing people affected. Read full story Source: BBC News, 14 February 2024
  14. Content Article
    The press has all been full of headlines about staffing levels in the NHS, but this is probably a problem across healthcare around the country. What this does is provide the perfect patient safety quandary, how do we keep all the areas safe. This often results in the redeployment of nursing staff to different areas, but does this provide the required levels of safety. It appears that having several areas in an “amber” staffing level is preferable than one red area. It is simple logic, but does this create an unrealistic expectation on staff that means the safety is better but only at a barely satisfactory level? Do we think that any of these decisions influences the efficiency of a ward? Is the ward safe and effective? In this blog, Chris Elston explores these issues and uses a Safety Engineering Initiative for Patient Safety (SEIPS) to show some of the lesser appreciated risks to redeploying staff and consider some ways to reduce the risks.
  15. News Article
    The family of a man who needlessly died after a 12-hour delay in surgery have called for changes at a troubled NHS trust as regulators expressed alarm about patient safety and waiting times. The Care Quality Commission (CQC) upgraded the surgery department at the Royal Sussex county hospital in Brighton from “inadequate” to “requires improvement” at a time when it is at the centre of a police investigation into dozens of patient deaths, allegations of negligence and cover-up. In their report, the regulator expressed concern about already long and lengthening waiting times, repeated cancelled operations and staff shortages that could compromise safety. The inspection report comes as the Guardian can reveal the trust apologised and settled with the family of Ralph Sims, who died aged 65 after heart surgery in April 2019 when doctors failed to act appropriately to a drop in his blood pressure. Sims, who was a keen runner, suffered a drop in blood pressure and developed an irregular heart rhythm eight hours after surgery to replace an aortic valve at the hospital. An internal investigation into Sims’ treatment acknowledged that hospital staff failed to “recognise the significance of the fall in blood pressure”. University Hospitals Sussex NHS foundation trust, which runs the hospital, accepted that the father of three should have returned to surgery to identify the cause of his deterioration. Instead, medics decided that he should be observed overnight. Due to another emergency case, an angiogram was not carried out on Sims until just before noon the following day – 12 hours after the drop in pressure. The delay caused irreversible – and avoidable – heart muscle damage, leading to his death five weeks later. The family said: It added: “Whilst the trust has apologised to our family it feels hollow. Ralph’s death was entirely unnecessary, and despite the issues in his care, it took the trust several years to apologise.” Read full story Source: The Guardian, 14 February 2024
  16. News Article
    England’s largest hospital trust has written to GPs warning their patients face 15-week waits for routine MRIs, ultrasound and CT scans. Guy’s and St Thomas’ Foundation Trust in central London said it was prioritising suspected cancer and other “urgent cases”, meaning “unfortunately waiting times for routine patients are now an average of 15-16 weeks for an appointment against a target of six weeks”. This is much worse than national averages, which December figures showed were 3.2 weeks, 2.5 weeks and 3.3 weeks for MRI, CT and ultrasound waits respectively. It its letter to GPs in Lambeth and Southwark – its main patches – GSTT said: “Current imaging referral demand outstrips capacity, despite these services consistently delivering near 120 per cent levels of activity compared to 2019-20. “The radiology service is exploring multiple routes to increase imaging capacity, including increased weekend working, insourcing and outsourcing contracts, but there is still a significant shortfall of slots every week.” In particular, it said primary care staff should expect long waits for the reporting of routine MRI scans. Read full story (paywalled) Source: HSJ, 13 February 2024
  17. Content Article
    The National Institute for Health Research (NIHR) awarded researchers from The Open University (OU), Manchester Metropolitan University, the Universities of Oxford, Glasgow and Edinburgh more than £141,000 to expand their world-first study of witnesses’ experience of giving evidence during health and social care workers’ professional conduct hearings. The project, Witness to harm, holding to account: Improving patient, family and colleague witnesses’ experiences of Fitness to Practise proceedings, mainly focuses on cases where there are allegations of harm. This focus should help regulators and employers identify potential improvements to support witnesses whose role in giving evidence is crucial to a fair hearing.
  18. Content Article
    Each week this newsletter contains new, useful, insightful or controversial content all about psychological safety research, applications, practice and opportunities to collaborate.
  19. Content Article
    How does it feel to confront a pandemic from the inside, one patient at a time? To bridge the gulf between a perilously unwell patient in quarantine and their distraught family outside? To be uncertain whether the protective equipment you wear fits the science or the size of the government stockpile? To strive your utmost to maintain your humanity even while barricaded behind visors and masks? Rachel is a palliative care doctor who looked after some of the most gravely unwell patients on the Covid-19 wards of her hospital. Amid the tensions, fatigue and rising death toll, she witnessed the courage of patients and NHS staff alike in conditions of unprecedented adversity. For all the bleakness and fear, she found that moments that could stop you in your tracks abounded. People who rose to their best, upon facing the worst, as a microbe laid waste to the population.
  20. News Article
    Hundreds of frontline NHS staff are treating patients despite being under investigation for their part in an alleged “industrial-scale” qualifications fraud. More than 700 nurses are caught up in a potential scandal, which a former head of the Royal College of Nursing said could put NHS patients at risk. The scam allegedly involves proxies impersonating nurses and taking a key test in Nigeria, which must be passed for them to become registered and allowed to work in the UK. “It’s very, very worrying if … there’s an organisation that’s involving themselves in fraudulent activity, enabling nurses to bypass these tests, or if they are using surrogates to do exams for them because the implication is that we end up in the UK with nurses who aren’t competent,” said Peter Carter, the ex-chief executive of the RCN and ex-chair of three NHS trusts. He praised the Nursing and Midwifery Council (NMC) for taking action against those involved “to protect the quality of care and patient safety and the reputation of nurses”. Nurses coming to work in the UK must be properly qualified, given nurses’ role in administering drugs and intravenous infusions and responding to emergencies such as a cardiac arrest, Carter added. Forty-eight of the nurses are already working as nurses in the NHS because the NMC is unable to rescind their admission to its register, which anyone wanting to work as a nurse or midwife in Britain has to be on. It has told them to retake the test to prove their skills are good enough to meet NHS standards but cannot suspend them. The 48 are due to face individual hearings, starting in March, at which they will be asked to explain how they apparently took and passed the computer-based test (CBT) of numeracy and clinical knowledge taken at the Yunnik test centre in the city of Ibadan. The times recorded raised suspicions because they were among the fastest the nursing regulator had ever seen. Read full story Source: The Guardian, 14 February 2024
  21. News Article
    More than 100 families looking after severely disabled adults and children outside hospital, have told the BBC that the NHS is failing to provide enough vital support. The NHS says help is based on individual needs and guidelines ensure consistency across England and Wales. However, some families describe the system as adversarial. Only those living outside hospital with life-limiting conditions, or at risk of severe harm if they don't have significant support, get this help from the NHS. It is provided through a scheme called Continuing Healthcare (CHC) for adults, and its equivalent for under-18s, Children and Young People's Continuing Care. Cases in England are decided by NHS Integrated Care Boards (ICBs) - panels responsible for planning local health and care services. In Wales, they are overseen by local health boards. The BBC has heard from 105 families who described serious concerns with how the two schemes are working - with most calling for reform. One young man with 24-hour needs hasn't received any CHC help despite being eligible since February 2023 - his parents, who first applied for support on his behalf nearly two years ago, currently provide round-the-clock care Another family were told overnight care for their teenage child - who is non-verbal, has severe mobility issues and requires 24/7 support - would be reduced from seven down to three nights a week, without a reason being given. Read full story Source: BBC News, 14 February 2024
  22. News Article
    There was an “unacceptable delay” and “failure to act with candour” in how a trust responded to a serious risk from staff nitrous oxide exposure, an independent investigation has found. Mid and South Essex Foundation Trust found levels of nitrous oxide far above the workplace exposure limit at Basildon Hospital’s maternity unit during routine testing in 2021. However, staff were only notified and a serious incident declared more than a year later. The exposure related to a mixture of nitrous oxide and oxygen, commonly known as gas and air, used during births. While short-term exposure is considered safe, prolonged exposure to nitrous oxide could lead to potential health issues. Chief executive Matthew Hopkins has apologised, after a report by the Good Governance Institute said: “The inquiry found that there was an unacceptable delay in responding to and mitigating a serious risk that had been reported… As a result of this failure to act on a known risk, midwives and staff members on the maternity unit were exposed to unnecessary risk or potential harm from July 6 2021 to October 2022." Read full story (paywalled) HSJ, 14 February 2024
  23. Content Article
    With the Maternity and Newborn Safety Investigations transition to the Care Quality Commission (CQC) completed, Sandy Lewis, Director of the Maternity Investigation Programme, reflects on past accomplishments, ambitions for 2024 and how the CQC transition is bedding in.
  24. Content Article
    Effective teamwork is critical to the provision of safe, effective healthcare. High functioning teams adapt to rapidly changing patient and environmental factors, preventing diagnostic and treatment errors. While the emphasis on teamwork and patient safety is relatively new, significant team-related foundational and implementation research exists in disciplines outside of healthcare. Social scientists, including, organizational psychologists, have expertise in the study of teams, multi-team units, and organizations. This article highlights guiding team science principles from the organisational psychology literature that can be applied to the study of teams in healthcare. The authorsʼ goal is to provide some common language and understanding around teams and teamwork. Additionally, they hope to impart an appreciation for the potential synergy present within clinician-social scientist collaborations.
  25. Event
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    Women’s Health Professional Care is designed for healthcare professionals and policymakers in primary and secondary care looking to improve health outcomes for women. Bringing together key learnings and new insights on a range of issues and challenges affecting women throughout their lives, Women’s Health Professional Care aims to address gender disparities in healthcare by highlighting areas of women’s health that have traditionally been overlooked. Register
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