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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
    This event gives trainees at all levels the opportunity to attend, present and gain feedback on their Audit and QI work. Further lectures will include the McKeown Medal Lecture, a keynote on patient safety and discussion from a Trainee Committee member. Trainees are invited to submit their abstracts for consideration for presentation at this event. Topics for submission: General Surgery, Trauma & Orthopaedic Surgery, Specialties & Common Interest and Patient Safety. Register
  2. Content Article
    The Royal College of Surgeons of Edinburgh 'Let's remove it' hub is a platform to tackle bullying and undermining across the surgical workforce.
  3. Content Article
    Surgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels. In the article 'Truth and compassion' (page 20-21), David Alderson considers the patient’s perspective on mistakes.
  4. Content Article
    The Patient Advocacy Leadership Collective (PALC) is an innovative hub that provides connectivity, community resources, and tools focused on sustainable capacity building for patient advocates globally. The PALC is an excellent platform with a focus on supporting the growth, development, and leadership of patient advocacy organizations and offers a NextGen Leadership, Mentorship, and Global Health Fellows programme.
  5. Content Article
    Postoperative surgical site infection is a serious problem. Coverage of sterile goods may be important to protect the goods from bacterial air contamination while awaiting surgery. This study from Wistrand and colleagues, evaluated the effectiveness of this practice in a systematic review covering five databases using search terms related to bacterial contamination in the operating room and on surgical instruments. No negative effects regarding bacterial contamination were found and the authors conclude that protection with a sterile cover decreases bacterial air contamination of sterile goods while waiting for surgery to start.
  6. Content Article
    The Patient Safety Indicators (PSIs) are a set of quality indicators developed by the Agency for Healthcare Research and Quality (AHRQ) providing information on potential hospital complications and adverse events after surgeries, procedures, and childbirth. They have been used for the past two decades in the USA for monitoring potentially preventable patient safety events in the inpatient setting through the automated screening of readily available administrative data. However, these indicators are also used for hospital benchmarking and cross-country comparisons in other nations with different health-care settings and coding systems as well as missing present on admission (POA) flags in the administrative data. This study sought to comprehensively assess and compare the validity of 16 PSIs in Switzerland, where they have not been previously applied.
  7. Event
    6th International Symposium: sharing experience and expertise on how patients and those close to them can improve safety of care today. The Symposium will hear from researchers and patients about their experience of complex modern healthcare. It will explore how to spot that things are going wrong, witness amazing new technology and map-out the ethical and legal implications of increased control of healthcare by patients. The event is in Bangor but will also broadcast content online on the day. Key topics for the 2024 event will be: Patient safety from the patient's (and family's) perspective. Patient Activated Critical Care & the policy discussion about Martha's rule. Patients held technology - empowering or distracting? Register
  8. Content Article
    This national learning report (NLR) draws on findings from investigation reports completed by the Healthcare Safety Investigation Branch (HSIB) that considered the risks associated with patient identification. ‘Positive patient identification’ is correctly identifying a patient to ensure that the right person receives their intended care. To support patient identification in England, the patient’s NHS number should be used alongside other identifiers, such as their name, date of birth and address. Patient misidentification is where a patient is identified as someone else. This may mean that a patient does not receive the care meant for them, or that they receive the care meant for someone else. Patient misidentification was highlighted as a risk to patient safety by the National Patient Safety Agency in the early 2000s. Despite the time that has passed, patient misidentification remains a persistent risk to patient safety that can result in significant harm. The aim of this NLR was to combine and analyse HSIB’s previous investigations and relevant international research literature, with the goal of informing national learning and influencing national actions to help reduce the risk of patient misidentification.
  9. Event
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    Join this free webinar to learn how collaboration and support for HSSIB (Health Services Safety Investigations Body) will make a difference and will promote a culture of safety in your organisation. During the course the webinar will explore what meaningful recommendations look like and how these recommendations will directly impact individual patient care, policy and strategy. Additionally, we will take a look at how the views of patients and healthcare professionals feed into building a Safety Management System. The primary aim of this webinar is to strengthen the relationship of HSSIB with those who work in the medical profession to aid understanding and future collaboration. By attending the webinar, you will: Gain and build your understanding of HSSIB. Be able to consider how we can contribute and support investigations. Be able to consider how we can contribute and support the implementation of recommendations. Register
  10. News Article
    Doctors have warned of the risks of “freebirthing” – where a woman gives birth without the help of a medic or midwife. Unassisted births, or “freebirths”, are thought to have been on the increase since the start of the Covid pandemic, when people may have been worried about attending hospitals and home births were suspended in many areas. The practice is not illegal and women have the right to decline any care during their pregnancy and delivery. Some women hire a doula to support them during birth. The Royal College of Obstetricians and Gynaecologists (RCOG) said women should be supported to have the birth they choose, but “safety is paramount” and families need to be aware of the risks of going it alone. The Nursing and Midwifery Council (NMC) said it is in the early stages of collaboration with the Chief Midwifery Officer’s teams, the Royal College of Midwives (RCM) and the Department of Health to better understand professional concerns about freebirthing and what organisations may need to do. Its statement on unassisted births supports women’s choice, but notes that “midwives are understandably concerned about women giving birth at home without assistance, as it brings with it increased risks to both the mother and baby”. It also states that women need to be informed that a midwife may not be available to be sent out to their home during labour if they change their mind and wish to have help. Read full story Source: The Independent, 8 February 2024
  11. News Article
    Harold Chugg spent much of early 2023 in a hospital bed because of worsening heart failure. During his most recent admission in June, the 75-year-old received several blood transfusions, which led to fluid accumulating in his lungs and tissues. Ordinarily, he would have remained in hospital for further days or weeks while the medical team got his fluid retention under control. But Harold was offered an alternative: admission to a virtual ward where he would be closely monitored in the comfort of his own home. Armed with a computer tablet, a Bluetooth-enabled blood pressure cuff and weighing scales, Harold returned to his farm near Chulmleigh in north Devon and logged his own symptoms and measurements daily, which were reviewed by a specialist nurse in another part of the county. Virtual wards provide hospital-level care in people’s homes through the use of apps, wearables and daily “virtual ward rounds” by medical staff, who review patient data and follow up with telephone calls or home visits where necessary. More than 10,000 such beds are already available across England and at least a further 15,000 are planned. Scotland, Wales and Northern Ireland are also funding their expansion. But while proponents claim patients in virtual wards recover at the same rate or faster than those treated in hospital, and that the wards’ provision can help cut waiting lists and costs, some worry that their rapid expansion could place additional strain on patients and caregivers while distracting from the need to invest in emergency care. “Virtual wards, if they deliver hospital-level processes of care, are just one part of the solution, not a panacea,” said Dr Tim Cooksley, a recent ex-president of the Society for Acute Medicine. Read full story Source: The Guardian, 7 February 2024
  12. News Article
    Campaigners have accused the UK government of betraying them after a review of redress for victims of health scandals excluded families who may have been affected by the hormone pregnancy test Primodos. A report published on Wednesday by the patient safety commissioner, Dr Henrietta Hughes, found a “clear case for redress” for thousands of women and children who suffered “avoidable harm” from the epilepsy treatment sodium valproate and from vaginal mesh implants. But despite the commissioner wanting to include families affected by hormone pregnancy tests in her review, the Department of Health and Social Care (DHSC) told her they would not be included. Primodos was an oral hormonal drug used between the 1950s and 70s for regulating menstrual cycles, and as a pregnancy test. Hormone pregnancy tests stopped being sold in the late 1970s and manufacturers have faced claims that such tests led to birth defects and miscarriages. Last year, the high court dismissed a case brought by more than 100 families to seek legal compensation owing to insufficient new evidence. The Hughes report states: “Our terms of reference did not include the issue of hormone pregnancy tests. This was a decision taken by DHSC and should not be interpreted as representing the views of the commissioner on the avoidable harm suffered in relation to hormone pregnancy tests or the action required to address this. “The patient safety commissioner wanted them included in the scope but, nevertheless, agreed to take on the work as defined by DHSC ministers.” Marie Lyon, the chair of the Association for Children Damaged by Hormone Pregnancy Tests, said the families of those who took the tests felt “left out in the cold” and betrayed that they were not included in the commissioner’s review. “I feel betrayed by the patient safety commissioner, by the IMMDS [Independent Medicines and Medical Devices Safety] review and by the secretary of state for health – all three have betrayed our families because, basically, they have just forgotten us. It’s a case of ‘it’s too difficult so we will just focus on valproate and mesh’,” Lyon said. Prof Carl Heneghan, a professor of evidence-based medicine at the University of Oxford, who led a systematic review of Primodos in 2018, said: “It’s unclear to me how the commissioner can keep patients safe if they are blocked and don’t have the power to go to areas where patient safety matters.” Read full story Source: The Guardian, 7 February 2024
  13. Content Article
    The NHS England National Patient Safety Team is seeking views on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement. The consultation runs from the 7 February until the 7 May 2024.
  14. News Article
    Families of children left disabled by an epilepsy drug and women injured by pelvic mesh implants should be given urgent financial help, England's patient safety commissioner has said. Dr Henrietta Hughes has called on the government to act quickly to help victims of the two health scandals. It follows a review which found lives had been ruined because concerns about some treatments were not listened to. It is estimated that, since the early 1970s, about 20,000 babies have been born with disabilities after foetal exposure to sodium valproate, which can harm unborn babies if taken in pregnancy. Scientific papers from as early as the 1980s suggested valproate medicines were dangerous to developing babies, yet warnings about the potential effects were not added to some packaging until 2016. Some families affected have been campaigning for decades to raise awareness of the potential effects of the drug, with some calling for compensation and a public inquiry. Dr Hughes was asked by the government to look into a potential compensation scheme for those affected by that scandal, as well as the one involving some 10,000 women who were injured by their pelvic mesh implants - a treatment for pelvic organ prolapse (POP) and incontinence. Read full story Source: BBC News, 7 February 2024
  15. News Article
    Bosses at hospitals where police are investigating dozens of deaths have been criticised for “bullying” and fostering a “culture of fear” among staff in a damning review by the Royal College of Surgeons in England. The review focused on concerns about patient safety and dysfunctional working practices in the general surgery departments at the Royal Sussex County hospital in Brighton and the Princess Royal hospital in nearby Haywards Heath. But the reviewers were so alarmed by reports of harassment, intimidation and mistreatment of whistleblowers that they suggested executives at the University Hospitals Sussex trust may have to be replaced. They concluded: “Consideration should be given to the suitability, professionalism and effectiveness of the current executive leadership team, given the concerning reports of bullying.” The report comes as Sussex police continue to investigate allegations of medical negligence and cover-up in the general surgery department and neurosurgery department, involving more than 100 patients, including at least 40 deaths, from 2015 to 2021. The investigation was prompted by concerns from a general surgeon, Krishna Singh, and a neurosurgeon, Mansoor Foroughi, who lost their jobs at the trust after blowing the whistle over patient safety. Read full story Source: The Guardian, 6 February 2024
  16. Content Article
    A common theme of recent international inquiries is that well intentioned investigations often make things worse. Harm is compounded when we fail to listen, validate and respond to the rights and needs of all the people involved. When lengthy processes do not result in meaningful action, suffering can be exacerbated and result in further damage to wellbeing, relationships, and trust. At its worst, compounded harm produces undesirable outcomes such as a community believing an essential service is unsafe, or a clinician leaving their profession. In considering how best to respond, it is important to remember that health systems are comprised of people and relationships, as well as rules and processes. Once we think about safety as a human and relational approach, rather than one that only seeks to lessen risk and enforce regulation, we can consider how to best proceed. Whether an act is intentional or not, a dignifying approach involves working together to repair the harm involved. Restorative responses are ideal for this purpose, as Jo Wailling, Co-chair of the National Collaborative for Restorative Initiatives in Health Aotearoa New Zealand, explains in this blog on the Patient Safety Commissioner website.
  17. Content Article
    ‘Patient-initiated follow-up’ (or PIFU, for short) is not a new idea and has been referred to in different ways over time, such as open-access appointments, self-managed follow-up, and see-on-symptom appointments. However, this approach has been given renewed attention given rising waiting times and the backlog of care that built up throughout the Covid-19 pandemic.  Moving outpatient attendances to patient-initiated follow-up (PIFU) pathways is considered a key part of plans to reduce outpatient follow-ups. But what exactly is PIFU? In this Nuffield Trust explainer, Sarah Reed and Nadia Crellin describe more about what it is, the problems it could solve, and what is known so far about how well it works.
  18. News Article
    A test that can detect oesophageal cancer at an earlier stage than current methods should be made more widely available to prevent deaths, charities have said. The capsule sponge test, previously known as Cytosponge, involves a patient swallowing a dissolvable pill on a string. The pill then releases a sponge which collects cells from the oesophagus as it is retrieved. The test can detect abnormalities that form as part of a condition known as Barrett’s oesophagus, which makes a person more likely to develop oesophageal cancer. In the UK 9,300 people are diagnosed with oesophageal cancer a year, according to Cancer Research. The disease is difficult to detect because the symptoms for the cancer are not easily recognisable – and can be mistaken for indigestion – until a it is at an advanced stage. The capsule sponge test can detect the cancer at an earlier stage than the current methods, such as an endoscopy, used to diagnose oesophageal cancer. However, it is only currently available to higher-risk patients as an alternative to endoscopy as part of NHS pilot schemes. Cancer Research UK is working with the National Institute for Health and Care Research (NIHR) on a trial that will recruit 120,000 people to see if the capsule sponge test can reduce deaths from oesophageal cancer. If successful, the test could be rolled out more widely. Mimi McCord, the founder of Heartburn Cancer UK, who lost her husband, Mike, to oesophageal cancer in 2002, said: “Cancer of the oesophagus is a killer that can hide in plain sight. People don’t always realise it, but not all heartburn is harmless. While they keep on treating the symptoms, the underlying cause might be killing them.” Read full story Source: The Guardian, 5 February 2024
  19. News Article
    The NHS Race and Health Observatory, in partnership with the Institute for Healthcare Improvement and supported by the Health Foundation, has established an innovative 15-month, peer-to-peer Learning and Action Network to address the gaps seen in severe maternal morbidity, perinatal mortality and neonatal morbidity between women of different ethnic groups. Across England, nine NHS Trusts and Integrated Care Systems will participate in this action oriented, fast-paced Learning and Action Network to improve outcomes in maternal and neonatal health. Through the Network, the nine sites will aim to address the gaps seen in severe maternal morbidity, perinatal mortality and neonatal morbidity between women of different ethnic groups. Haemorrhage, preterm birth, post-partum depression and gestational diabetes have been identified as some of the priority areas for the programme. The sites will generate tailored action plans with the aim of identifying interventions and approaches that reduce health inequalities and enhance anti-racism practices and learning from the programme. These will be evaluated and shared across and between healthcare systems. The Network, the first of its kind for the NHS, will combine Quality Improvement methods with explicit anti-racism principles to drive clinical transformation, and aims to enable system-wide change. Over a series of action, learning and coaching sessions, participants will review policies, processes and workforce metrics; share insights and case studies; and engage with mothers, parents, pregnant women and people. The programme will run until June 2025, supported by an advisory group from the NHS Race and Health Observatory, Institute for Healthcare Improvement, and experts in midwifery, maternal and neonatal medicine. Read full story Source: NHS Race and Health Observatory, 24 January 2024
  20. Content Article
    The National Quality and Patient Safety Directorate (NQPSD) is a team of healthcare professionals working within the national Health Service Executive (HSE) Ireland to improve patient safety and quality of care. They work in collaboration with Health Service Executive operations, patient partners, healthcare workers and other internal and external partners. Their work is guided by the Patient Safety Strategy 2019-2024. 
  21. News Article
    Working with physician and anaesthesia associates actually increases a doctor’s workload rather than freeing up time to focus on care of patients, a BMA survey finds.1 The association surveyed more than 18 000 UK doctors to inform its position on physician and anaesthesia associates. Some 55% (7397 of 13 344 who responded to this question) reported that their workload had risen since the employment of medical associate professionals, with only 21% (2799 of 13 344) reporting a decreased workload. The House of Lords will shortly consider legislation to regulate physician associates under the General Medical Council rather than the Health and Care Professions Council. Read full story (paywalled) Source: BMJ, 2 February 2024
  22. News Article
    A nurse whistleblower has described her eight years of hell as she fights the NHS over its failure to properly investigate claims she was sexually harassed by a colleague. Michelle Russell, who has 30 years of experience, first raised allegations of sexual harassment by a male nurse to managers at the mental health unit where she worked in London in 2015. Years of battling her case saw the trust’s initial investigation condemned as “catastrophically flawed” while the nursing watchdog, the Nursing Midwifery Council, has apologised for taking so long to review her complaint and has referred itself to its own regulator over the matter. With the case still unresolved, Ms Russell will see her career in the NHS end this week after she was not offered any further contract work. Speaking to The Independent she said: “If I’m going to lose my job, I want other nurses to know that this is what happens when you raise a concern. I want the public to know this is what happens to us in the NHS when we are trying to protect the public. “I have an unblemished career. They’re crying out for nurses. I’ve dedicated my life to the NHS. I haven’t done anything wrong.” Read full story Source: The Independent, 6 February 2024
  23. Content Article
    This article in the Nursing Times explores reflective practice in community nursing, focusing on a stressful incident in which a patient who had not been contactable during a home visit was later found to have died. The article emphasises the necessity of structured reflection, utilising Rolfe’s reflective model, to explore nurses’ feelings. It delves into the model’s stages, its impact on critical thinking and guiding reflection through questions, and highlights the importance of reflective practice, emphasising its role in learning, professional development and improving patient outcomes. The article concludes by showcasing the successful implementation of a new model and its positive impact on patient safety in home visits, providing a structured approach for nurses and health professionals.
  24. Content Article
    New research shows that more independent hospitals are rated as “good” or “outstanding” than ever before, despite the challenges posed by the pandemic and the subsequent period of health system recovery.  The Independent Healthcare Providers Network (IHPN) conducted a national review of quality and safety data across the sector, looking at a broad range of datasets to evaluate quality and safety in key areas, analysing data from the Care Quality Commission (CQC). 
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