Jump to content
 View Profile  See their activity

  • Posts

    11,906

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

Everything posted by Patient Safety Learning

  1. Content Article
    On 9 January 2024, the All-Party Parliamentary Group (APPG) on birth trauma in the UK Parliament will set up an inquiry to investigate the reasons for traumatic birth and to develop policy recommendations to reduce the rate of birth trauma. Research shows that about 4–5% of women develop post-traumatic stress disorder (PTSD) after giving birth – equivalent to approximately 25,000-30,000 women every year in the UK. Studies have also found that a much larger number of women – as many as one in three – find some aspects of their birth experience traumatic. Birth trauma affects 30,000 women across the country every year. 53% of women who experienced birth trauma are less likely to have children in the future and 84% of women who experienced tears during birth, did not receive enough information about birth injuries ahead of time.  
  2. Event
    Speaker: Professor Ian Leistikow; Adviser at the Dutch Health & Youth Care Inspectorate and Professor at Erasmus School of Health Policy & Management, Erasmus University Rotterdam, the Netherlands Challenges that health and care faces, translate to challenges for the regulatory authorities. Classic regulatory strategies aimed at compliance increasingly fall short in contributing to quality of (health)care. In this webinar Ian will use the model of ‘value driven regulation’ to show how the Dutch Inspectorate strives to keep up with the dynamics of the sectors it regulates, by keeping its eye on creating societal value. Ian will also give an overview of the broad range of scientific research projects within the Inspectorate aimed at improving the positive impact of its regulation. Find out more
  3. News Article
    Community Pharmacy Scotland (CPS) is calling for all pharmacy staff to be allowed to prepare and assemble medication without requiring supervision from a pharmacist or pharmacy technician. Its comments came in its response to a Department of Health and Social Care consultation on pharmacy supervision, published on 7 December 2023, which sets out proposals to amend the Medicines Act 1968 and The Human Medicines Regulations 2012. The consultation includes proposals to enable pharmacists to authorise pharmacy technicians to carry out, or supervise others carrying out, the preparation, assembly, dispensing, sale and supply of medicine; to enable pharmacists to authorise any member of the pharmacy team to hand out checked and bagged prescriptions in the absence of a pharmacist; and to allow pharmacy technicians to supervise the preparation, assembly and dispensing of medicines in hospital aseptic facilities In its response, the CPS disagreed with the first of these proposals, arguing that “the preparation and assembly of [pharmacy] and [prescription-only] medications can be safely carried out from a registered pharmacy premises, without requiring supervision by a Responsible Pharmacist or an authorised pharmacy technician”. CPS also said there is “a major flaw in the logic” of the government proposal because “it relies heavily on individuals rather than on safe systems”, making the proposed new way of working “vulnerable to changes in personal circumstance”. “The environment, technology, training, conditions and [standard operating procedures] in the community pharmacy setting have a bigger effect on safety of preparation and assembly than supervision by an individual,” the response said. Read full story Source: The Pharmaceutical Journal, 12 February 2024
  4. Content Article
    The aim of this study, published in the BMJ, was to evaluate whether a structured online supervised group physical and mental health rehabilitation programme can improve health related quality of life compared with usual care in adults with Long Covid.  Best practice usual care was a single online session of advice and support with a trained practitioner. The REGAIN intervention was delivered online over eight weeks and consisted of weekly home based, live, supervised, group exercise and psychological support sessions. The authors concluded that in adults with Long Covid, an online, home based, supervised, group physical and mental health rehabilitation programme was clinically effective at improving health related quality of life at 3 and 12 months compared with usual care.
  5. Content Article
    In a new series of blogs, Dawn Stott, Business Consultant and former CEO of the Association for Perioperative Practice (AfPP), discusses how coaching and developing teams can support patient safety and its outcomes.  In part one, Dawn looked at the strategies and coaching methodologies that can be used to develop individuals and to support patient safety. In part two, Dawn looks at how coaching can improve individuals, and discusses the indicators of improvement, prosocial behaviours and the importance of good communication to improve culture and, ultimately, patient safety.
  6. Event
  7. Content Article
    This project aims to develop peer consensus centred on specific themes defined by the steering group covering topics relevant to the optimal, universal and evidence-based care bundle to reduce surgical site infections (SSIs). It will support building expert consensus around best practices when selecting the care bundle to reduce surgical site infections in practice. It is hoped that the output will support best practice patient management in Europe. The survey takes under 10 minutes to complete. Please review each statement and indicate your level of agreement with it (tick one box only per statement). Please only complete this questionnaire once. Your anonymous responses will be a source of data for the development of a consensus publication. This project has been initiated and funded by Becton Dickinson and is being managed and delivered by Triducive.
  8. News Article
    The trusts where maternity care has deteriorated the most according to patient surveys have been identified by the Care Quality Commission. The regulator collected responses from 25,515 patients about their experiences of antenatal care, labour, birth and postnatal care across 121 trusts in February 2023. It then analysed where experiences of care were substantially better or worse overall when compared with survey results across all trusts in England. Survey responses also painted a deteriorating picture of maternity care nationally, with answers to 11 questions showing a statistically significant downward trend compared to five years ago. Five trusts were categorised as “worse than expected”, where patients’ experiences of using their services were substantially worse than the average. Read full story (paywalled) Source: HSJ, 12 February 2024
  9. News Article
    Dozens of new allegations of sexual assault and abuse, including claims of rape and of patients being made pregnant, have emerged following an investigation into Britain’s mental health wards. One patient with a mental health disorder became pregnant by a member of staff. Allegations of rape, and of children being groomed by healthcare assistants, were among the 40 horrifying new reports of abuse made against rogue NHS Trusts. The investigation, conducted by The Independent, alongside Sky News, revealed more than 20,000 allegations of sexual assault and harassment across more than 30 NHS England mental health trusts since 2019. Several patients, who have come forward with their own harrowing stories, had allegedly been harmed by healthcare assistants, who currently are not regulated. Natalie, whose name has been changed, was one of several patients groomed and asked to share sexually explicit photos by a healthcare assistant working at a children’s mental health ward in 2020. Natalie, who was 16 at the time, told The Independent: “The first few conversations [after I was discharged] were very innocent. However after weeks and months, he started speaking in a sexual nature, asking me to send explicit photos of myself, posting explicit photos of himself and asking to meet up for sexual advances, I didn’t realise it at the time, but he was grooming me; this was all over Snapchat. “I feel and still feel very small, and that I wasn’t looked at as a person [by the hospital], and they only saw me as a patient with no feelings that mattered. It felt like another incident at ... that just got swept under the rug.” Read full story Source: The Independent, 10 February 2024
  10. Content Article
    In November 2023, the Parliament’s Justice Select Committee launched a follow-up inquiry to The Coroner Service, to examine changes and progress since the first inquiry in 2020-2021.
  11. News Article
    NHS England is in negotiations with ministers to formally push back the target to eliminate 65-week waiters, HSJ has learned. Discussions about the target are on-going as part of negotiations around the delayed 2024-25 planning guidance. It has been clear for months the March deadline to virtually eliminate 65-week waiters would be missed. It has emerged some trusts with the largest waiting lists already appear to be working to a September deadline. The news follows prime minister Rishi Sunak being forced to finally admit this week that his flagship NHS pledge from last January, that the waiting list would be falling by this year, had failed. This was something NHS bosses have warned of since summer. Read full story (paywalled) Source: HSJ, 9 February 2024Choose Single File...
  12. News Article
    ‘This is a very painful thing to admit,” says Emily Roberts, a 47-year-old teacher from south London, “but my entire adult life has been shaped by trying to survive what has been done to me.” Roberts (not her real name) is one of hundreds of British people who believe that they have been unintentionally maimed by orthodontists — dentists who specialise in irregular teeth and jaws. Along with thousands of others around the world, they share their experiences and post photographs and x-rays on Facebook groups. They say that lifelong damage was done to them as children — not by shady backstreet operators but by regular high street practitioners. Many say that as a result their adult lives have been blighted by painful and debilitating symptoms. “I’ve spent my entire adult life working on my body to try to get my posture right or get out of pain,” Roberts says. She has seen neurologists, osteopaths, pain-management specialists. Nothing has worked. She considered taking legal action against the orthodontist who initially treated her — for seven years in total — but the UK’s statute of limitations states that claims for dental negligence must be made within three years of the treatment and the time limit elapsed while she was still considering her options. Lauren Packham, 36, was 12 years old when she had four premolar teeth removed to correct an overbite that she says “wasn’t even that bad”. She then wore fixed braces and elastics to retract her teeth. In her twenties she had three wisdom teeth removed after they became painful. “If I knew what I know now, I wouldn’t have had them out,” she says. In the past few years Packham, who lives in Plymouth, has suffered worsening jaw pain and migraines. She has also experienced sleep problems since her late teens. “If I sleep on my back, my breathing just cuts off. I’ve since had a diagnosis of sleep-disordered breathing.” A Harley Street sleep specialist doctor she saw privately pointed to her orthodontic treatment as the likely cause of her health issues. Read full story (paywalled) Source: The Times, 11 February 2024 Further reading on the hub: “I’ve been mocked, scolded and gaslighted”: a harmed patient’s experience of orthodontic treatment A patient harmed by orthodontic treatment shares their story Share your experience of orthodontist and dentistry services
  13. Community Post
    An article in The Times over the weekend: The ‘unnecessary’ NHS teeth extractions that led to lifetimes of pain (thetimes.co.uk)
  14. News Article
    Lawyers and charities tell of mothers told to ‘labour at home as long as they can’, dangerously few midwives and ‘lies’ during natal care. As Rozelle Bosch approached her due date she had every reason to expect a healthy baby. Neither she, her husband nor the midwives knew that the child was in the breech position at 30 weeks. When her waters broke a fortnight early, Bosch and her husband, Eckhardt, both first-time parents, had been reassured by NHS Lanarkshire that all was well and that the mother was “low risk”. They were sent home from Wishaw hospital and told to monitor conditions until the pregnancy became “active”. Shortly before 11pm on 1 July 2021, her husband called an ambulance saying that Bosch was in labour and was giving birth. Bosch was in an upstairs bedroom on her knees and paramedics noted that “the baby was pink”. They soon asked the control room for a doctor or midwife to attend but none were available. By the time the ambulance took the family to hospital, the baby had turned blue. Within two days, baby Mirabelle had died. She had become trapped with only her feet and calves delivered while the couple were still at home. A post-mortem has found that Mirabelle suffered oxygen deprivation to the brain from “head entrapment” during delivery. Last month, her father explained to a fatal accident inquiry (FAI) at Glasgow sheriff court: “We were told Rozelle was healthy and Mirabelle was healthy. I think this was a lie and the consequences have me standing here today.” The way that the tragedy unfolded is striking, not just because of the devastating consequences, but because it is not an entirely isolated case. The same FAI is examining the deaths of two other newborns, Ellie McCormick and Leo Lamont, who also died in NHS Lanarkshire less than a month apart in 2019. Experts say it is rare for the Crown and Procurator Fiscal Service to group investigations in this way. Darren Deery, the McCormicks’ lawyer and a medical negligence specialist with Drummond Miller, said he had noticed a “considerable increase” in parents contacting the law firm in the past three years. Read full story (paywalled) Source: The Times, 11 February 2024
  15. News Article
    An investigation has been launched after a woman died days after being found unconscious underneath her coat while waiting in A&E for seven hours. The 39-year-old woman is understood to have first attended A&E at Queen’s Medical Centre in Nottingham on the evening of 19 January complaining of a severe headache. She was triaged and then observed by nurses three times. Her case was escalated but she was not seen by a doctor before being discovered. When the woman was called to see a doctor, she did not respond. It was assumed that she had left A&E because she had waited so long. She was discovered and transferred to intensive care but died three days later on 22 January. A source familiar with the hospital told LBC, which first reported the incident, that the A&E department could have up to 80 patients waiting at a single time and that wait times could be as long as 14 hours. Dr Keith Girling, the medical director at Nottingham university hospitals NHS trust, said: “I offer my sincere condolences to the family at this difficult time. An investigation, which will involve the family, will now take place and until this has been concluded, we are unable to comment further.” Read full story Source: The Guardian, 10 February 2024
  16. Content Article
    Dr Phil Hammond dissects the medical lives of professionals at all levels of the health service in his podcast, Doctor, Doctor. In this episode, he speaks to Dr Rosie Benneyworth, interim Chief Executive Officer of the Health Services Safety Investigations Body (HSSIB).
  17. Content Article
    There are many unheard and under-acknowledged voices and perspectives in the health and social care workforce, and they usually belong to those in the most junior, poorest-paid and precarious roles. All these voices deserve more attention than they get, but those of newly qualified and registered nurses and midwives are especially important given the current retention crisis in both professions. Since spring 2023, the King's Fund have been working with 22 newly qualified - newly registered if they trained internationally – nurses and midwives on a project called Follow Your Compassion. A documentary record of the everyday working lives of these nurses and midwives across a variety of settings across the UK health and care system, the project is a companion piece to The Courage of Compassion (2020), a report by The King’s Fund and RCN Foundation which described the core workplace needs of nurses and midwives, and what must be done to meet them.
  18. Content Article
    Despite progress on patient safety since the publication of the Institute of Medicine’s 1999 report, To Err Is Human, significant problems remain. Human factors and systems engineering (HF/SE) has been increasingly recognized and advocated for its value in understanding, improving, and redesigning processes for safer care, especially for complex interacting sociotechnical systems. However, broad awareness of HF/SE and its adoption into safety improvement work have been frustratingly slow. We provide an overview of HF/SE, its demonstrated value to a wide range of patient safety problems (in particular, medication safety), and challenges to its broader implementation across health care. We make a variety of recommendations to maximise the spread of HF/SE, including formal and informal education programmes, greater adoption of HF/SE by health care organisations, expanded funding to foster more clinician-engineer partnerships, and coordinated national efforts to design and operationalise a system for spreading HF/SE into health care nationally.
  19. News Article
    The first time she was groped at work, Freya says she was 24 years old, a newly qualified paramedic, and was cleaning out the cupboards of the ambulance station crew room. "He came behind me without me realising. I was cleaning away, and he put his hands around my body and grabbed my breasts," said Freya, which is not her real name. "Then he said, 'Well, I won't bother doing that again'. "People just laughed, some didn't even look up from the TV. Like it was nothing, completely normal." Her story mirrors that of other current and former paramedics who, in several interviews with Sky News, painted a picture of widespread sexual harassment and a toxic culture of misogyny. The head of the College of Paramedics, Tracy Nicholls, said: "Problems exist in every [NHS] trust, across all four countries in the United Kingdom." NHS England told Sky News that any form of sexual misconduct was "completely unacceptable" and every trust had committed to an action plan to improve sexual safety. Laura - not her real name - is currently a paramedic for a different ambulance service. She describes sexual harassment as "incessant" in the profession. She says students and new recruits are routinely referred to as "fresh meat", subjected to sexual comments, questions and jokes - even in front of patients - and are continually sexualised by some male colleagues. "It's exhausting," she said. "You come to work wanting to help your patients but every day you're dealing with inappropriate behaviour and sexual comments." Read full story Source: Sky News, 8 February 2024
  20. Content Article
    Prolonged length of stay (LOS) in emergency departments (ED) is a widespread problem in every hospital around the globe. Multiple factors cause it and can have a negative impact on the quality of care provided to the patients and the patient satisfaction rates. This project aimed to ensure that the average LOS of patients in a tertiary care cancer hospital stays below 3 hours. 
  21. Content Article
    In the fast-evolving realm of contemporary healthcare, surgical techniques have attained unprecedented levels of advancement, leading to substantial enhancements in patient care. However, the journey towards complete recovery extends far beyond the operating room, emphasising the importance of effective postoperative care. In this critical phase, patient partnerships play a pivotal role, ensuring a holistic and personalised approach to recovery.
  22. News Article
    The number of patients waiting more than 12 hours in A&E hit a record in January of almost 180,000 people. Worsening pressures on A&E come as prime minister Rishi Sunak has officially missed his pledge, made in January last year, to cut the NHS waiting list. NHS England began publishing previously-hidden data on patients waiting 12 hours or more last year, after reports by The Independent. The latest figures for January show 178,000 people were waiting this long to be seen, treated or discharged after arriving from A&E – a record since February 2023 when the data was first published. In that month, 128,580 people waited more than 12 hours, and in December there were 156,000. The number waiting at least four hours from the decision to admit to actual admission has also risen, from 148,282 in December to 158,721 last month – the second-highest figure on record. Dr Tim Cooksley, past president of the Society for Acute Medicine, warned: “Degrading corridor care and prolonged waits causing significant harm is tragically and increasingly the expected state in urgent and emergency care.” Read full story Source: The Independent, 8 February 2024
  23. News Article
    Cancer waiting times for 2023 in England were the worst on record, a BBC News analysis has revealed. Only 64.1% of patients started treatment within 62 days of cancer being suspected, meaning nearly 100,000 waited longer than they should for life-saving care. The waits have worsened every year for the past 11. Macmillan Cancer Support chief executive Gemma Peters called the figures "shocking". "This marks a new low and highlights the desperate situation for people living with cancer," she said. "Behind the figures are real lives being turned upside down, with thousands of people waiting far too long to find out if they have cancer and to begin their treatment, causing additional anxiety at what is already a very difficult time. "With over three million people in the UK living with cancer and an ageing population, this is only set to rise." The records go back to 2010, shortly after the cancer target was introduced. However, improvements have been made over the course of 2023 in how quickly patients are diagnosed with 72% told whether they have cancer or not within 28 days of an urgent referral. Read full story Source: BBC News, 8 February 2024
  24. News Article
    A senior surgeon has raised concerns about the way whistleblowers are dealt with, claiming he was sacked after speaking out. Serryth Colbert told the BBC that following attempts to "stop wrongdoing", he was investigated by the trust at Bath's Royal United Hospital. As a result, he said he was dismissed for gross misconduct in October 2023. The RUH said it has "never dismissed anybody for raising concerns and never will". It added that Mr Colbert's dismissal related to "significant concerns about bullying" and its investigation into his conduct was "thorough" and "robust". Mr Colbert said he raised safety concerns without regard for the impact it might have on his career. "It was never a question in my mind. This is wrong. I'm stopping the wrongdoing. I stand for justice. I stand to protect patients," he said. The BBC has seen no evidence his most serious concern was ever investigated and Mr Colbert is now taking the RUH to an employment tribunal. Read full story Source: BBC News, 9 February 2024
  25. Content Article
    The relationship between the fields of human factors and patient safety is relatively nascent but represents a powerful interaction that has developed in only the last twenty years. Application of human factors principles, techniques, and science can facilitate the development of healthcare systems, protocols, and technology that leverage the enormous and adaptable capacity of human performance while acknowledging human vulnerability and decreasing the risk of error during patient care. This chapter will review these concepts and employ case studies from neonatal care to demonstrate how an understanding of human factors can be applied to improve patient safety.
×
×
  • Create New...