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Patient Safety Learning

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  1. Event
    until
    The institution of medicine has always excluded women. From ancient beliefs that the womb wandered through the body causing 'humours' to 19th century Freudian hysteria, female bodies have been marked as unruly, defective, and lesser. We are still feeling the effects of these beliefs today. In 2008, a study of over 16,000 images in anatomy textbooks found that the white, heterosexual male was presented as the ‘universal model’ of a human being. We see this play out in medical research, when it isn't considered necessary to include women's experiences: approximately 70% of people who experience chronic pain are women, and yet 80% of pain study participants are men or male rats. We also see these beliefs inform clinical decisions. When experiencing pain, women are more likely to be given sedatives than painkillers, in a nod to the stereotype that women are more emotional and are therefore probably exaggerating the nature of their pain. This phenomenon is known as the gender pain gap, which describes the disparities in medical care that men and women receive purely due to their gender. But while awareness has risen over the last few years, how close are we to really closing the gender pain gap? Join The Femedic and Hysterical Women in discussion with Dr Omon Imohi, Dr Hannah Short, and research charity Wellbeing of Women as we consider how far medicine has come and how far we still have to go. Register
  2. Content Article
    This Health Service Journal (HSJ) article explores how executive leaders can drive improvement by focusing on developing an organisational culture, building up staff in an open, just, and empowering environment, thereby enabling organisations to meet the challenges of the new and uncertain healthcare environment.
  3. News Article
    The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found. Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday. The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing". The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest". Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home. Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided". He said: "There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later." "Instead, a cover-up began on the day that she died, propped up by denial and deception." Read full story Source: BBC News, 26 November 2020 Patient Safety Learning's statement on the Dixon Inquiry report
  4. Content Article
    A report on the investigation into the death of Elizabeth Dixon and a series of recommendations in respect of the failures in the care she received from the NHS.
  5. Content Article
    Over the past 12 years, the number of emergency hospital admissions in England has increased by 42%, from 4.25 million in 2006/07 to 6.02 million in 2017/18. Over 60% of patients admitted to hospital as an emergency have one or more long-term health conditions such as asthma, diabetes or mental illness. Patients with long-term conditions spend under 1% of their time in contact with health professionals. The majority of their care, such as monitoring their symptoms and administering medication and treatment, comprises tasks they or their carers manage on a daily basis. To find out how able patients currently feel to manage their health conditions, the Health Foundation looked at Patient Activation Measure (PAM) scores, which assess four levels of knowledge, skill and confidence in self-management, for over 9,000 adults with long-term conditions. In this briefing, the Health Foundation assesses the evidence for the effectiveness of a range of approaches the NHS could use more often to support patients to manage their health conditions. These include: health coaching, self-management support through apps, social prescribing initiatives and peer support including via online communities. 
  6. Content Article
    The increased use of personal protective equipment (PPE) during the COVID-19 pandemic has added challenges for healthcare workers and accessing the right PPE, or having the right equipment and staff, can be difficult. This guidance from Royal College of Physicians (RCP) aims to help individuals working in healthcare to ensure PPE use does not impair patient safety. This guidance, created by the RCP Medicine Safety Joint Working Group and led by the RCP’s Medicines safety clinical fellow, Jennifer Flatman, aims to raise awareness of key issues relating to the use of PPE. It includes recommendations on how you can help to mitigate against patient safety issues related to PPE in your healthcare environment and considers scenarios such as use of PPE when performing tasks and situational awareness.
  7. Content Article
    An error trap is a situation that could lead into avoidable harm if not mitigated. It is a situation where the circumstances in combination with human cognitive limitations make errors more likely.[1] Error traps can be found throughout health and social care in medicines, equipment and devices, in documentation, and in many other areas we see every day while going about our daily jobs in health and social care. We want to raise awareness of these error traps on the hub but more importantly we want to hear your suggestions of what needs to be done to prevent them and examples of where action has been take and worked. View our error trap gallery and share your examples.
  8. Content Article
    This report provides an update on patient safety matters at the National Institute for Health and Care Excellence (NICE) for the period of September 2019 to September 2020. The board paper proposes NICE develops a unified approach to patient safety, integrating the work already occurring in different parts of the organisation. It will build on existing structures and draw on the expertise of the Science, Evidence and Analytics Directorate to consider how new technology such as artificial intelligence could help detect patient safety signals more quickly in the future. The work will also explore how patient safety at NICE can evolve and integrate with NICE Connect, their multiyear project which will transform the way they produce and present their guidance and the lives of people receiving care.
  9. Content Article
    Care provided by families valued at £135 billion over course of the pandemic so far. Carers UK calls on Government to recognise contribution of millions of carers and protect their health and wellbeing Research, released for Carers Rights Day, estimates that the care provided by people looking after older, disabled and seriously ill relatives and friends during the pandemic stands at £135 billion so far, after just eight months. Previous research by the charity found that the majority (81%) of carers have been taking on more care since the start of the pandemic and nearly two thirds (63%) are worried about how they will continue to manage over winter. Carers UK is calling on the Government to provide additional support for carers over winter and ensure those caring for more than 50 hours a week get access to a funded break. With many crucial face-to-face support services such as day centres and support groups significantly reduced – or in many cases closed – because of costly infection and control measures, Carers UK is warning that people caring round the clock are going to break down after months of caring without respite.
  10. News Article
    A network of specialist surgical mesh removal centres is to be set up around England, with a launch planned for April 2021. The move implements a recommendation of the review, chaired by the Conservative peer and former health minister Julia Cumberlege, into three treatments which caused avoidable harm. These included the use of transvaginal tape and pelvic mesh to treat pelvic organ prolapse and urinary incontinence. The review, which published its report in July, heard “harrowing” stories about women left with serious complications. The mesh is hard to remove and only a few surgeons in the UK are able to carry out the procedure. Read full story (paywalled) Source: BMJ, 25 November 2020
  11. News Article
    NHS trust chief executives have told HSJ they need more clarity the Pfizer-BioNTech covid vaccine is safe to reassure their worried staff. Trusts were told last week they need to be ready to start vaccinating their staff from early next month. On Tuesday, it was confirmed that they would initially be asked to use the covid vaccine produced by Pfizer and BioNTech, assuming it is granted a licence by the Medicines and Healthcare products Regulatory Agency. Speaking at the HSJ Provider Virtual Summit, St George’s University Hospitals Foundation Trust chief executive Jacqueline Totterdell said there was a lot of “anxiety” around the vaccine among her staff. Leeds Community Healthcare Trust chief Thea Stein added leaders in her city feel “anxious and uncertain”. Ms Totterdell said: “As a responsible officer for 9,000 staff, I also need to be clear that the vaccination is safe. That bit of narrative just needs to come out from the centre, about the reasons why they think it is safe. “I think there is a lot of anxiety, and some of the polls we’ve done around south west London show that as little as 50 per cent of people are willing just to have it without any of that [assurance]." Northumbria Healthcare FT chief executive Sir Jim Mackey, who also spoke at the summit, admitted he was “a bit surprised” by some staff who said they were not going to get the vaccine. The former NHS Improvement chief added: “I think when it actually comes to it, and we get the messaging right about it, not just the responsibility for you but also your responsibility for the people you work with… then the vast majority of people will get it and take confidence in the fact that it’s been developed really quickly and effectively. “These things don’t get signed off if they’re dangerous, so we need to embrace it as the thing that’s going to get us back to normal.” Read full story (paywalled) Source: HSJ, 26 November 2020
  12. News Article
    Ministers are to invest millions in making Britain's maternity wards safer, it was announced on Wednesday after The Independent exposed a series of cases in which mothers and babies had suffered avoidable harm during childbirth. The new money, almost £10m, was announced as part of the spending review unveiled by Rishi Sunak, the chancellor, in the Commons and will deliver new pilots of what the Treasury called “cutting-edge training” to improve practice during childbirth. Significant failings in maternity safety units across the NHS have devastated families and left some babies needing tens of millions of pounds to look after them in later life. In November last year, The Independent joined with the charity Baby Lifeline to call for a new fund to be set up after exposing the single largest maternity scandal in NHS history at Shrewsbury and Telford Hospitals Trust, where dozens of babies have died or been left with brain damage. The new funding will also cover the final year of the independent investigation into the Shrewsbury trust. Read full story Source: The Independent, 26 November 2020
  13. News Article
    Emergency care leaders are warning it will take up to six more months to determine whether pilots of a radical change to accident and emergency are working, even though it is due to go live nationally next week, HSJ has learned. HSJ understands the new “111 First” system — where walk-in patients not in medical emergencies call 111 to “book” urgent care — is set to “go live” across England from next week following pilots in acute trusts which have been run since the summer. From 1 December, people will be able to call NHS 111 from anywhere in the country and have urgent care “booked” for them if needed, it is understood. NHS England has been pursuing the 111 First model to help reduce overcrowding and the risk of nosocomial infections in A&Es. The service is also intended to be able to book them into GP practice appointments. Well-placed sources confirmed most acute trusts have now implemented some form of 111 First and the model is set to be part of their standard operations when the national system “goes live” next week. A national advertising campaign is expected to promote the approach. But the Royal College of Emergency Care Medicine said there was a “vocal minority” of clinicians who are “vehemently against” 111 First as they believe it will increase demand in emergency departments. Read full story (paywalled) Source: HSJ, 25 November 2020
  14. News Article
    While both ME and long Covid, or post-Covid syndrome, are long-term illnesses, they aren’t the same thing. But, there are ways in which our knowledge of ME has helped experts treat long Covid. It’s also helped those with the illness understand what they’re going through. Evan was diagnosed with ME in 2017, and she believes her experience can help her support those living with long Covid. Watch video Source: BBC News, 26 November 2020
  15. Content Article
    For some, the day we learned of our rare disease diagnosis is a happy day. Odd, isn’t it? Imagine having your closest friends and family thinking that you are overreacting a bit, or that you are searching for some attention? It might be frustrating! Having a diagnosis can be very important, not only in order to consider medical needs, but sometimes it can also come as proof that something is happening to the body, proof to others that there is something going on. Several people across the globe, with different rare diseases, have shared their story, telling us about needing to be heard and understood.
  16. Content Article
    If you have a rare disease, the search for a diagnosis can often feel like the longest detective investigation - with no clues, lots of blind alleys and, occasionally, disbelieving authorities. It may seem like things are going nowhere, even for years. Sometimes this is because information on the condition just isn’t available and not enough research has been done; other times it’s difficult to find someone knowledgeable enough to spot the signs of a rare disease. After all, these diseases are so rare that many doctors have never come across them in their careers. Either way, a person with a rare disease can end up playing investigator in their own personal medical mystery – and in some situations even end up solving the case, or devising treatment, for themselves! Read some stories from patients.
  17. Event
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    How are we ensuring that patient and staff safety is being prioritised during the pandemic? Presenters: Helen Hughes, Chief Executive, Patient Safety Learning, Dr Abdulelah Alhawsawi, Director General, Saudi Patient Safety Center, Professor Ted Baker, Chief Inspector of Hospitals, Care Quality Commission It can be argued that staff safety has not been prioritised as it should have been in recent years. The Covid-19 pandemic has reinforced this. It has exposed risks to staff physical and mental wellbeing, with inadequate Personal Protective Equipment (PPE), intensely difficult physical and psychological working conditions, and, tragically, it has resulted in deaths from exposure to Covid-19 as a result of inadequate infection control. The importance of overarching leadership for patient safety in health and social care is a key concept. Ensuring that leaders embed staff safety into safety programmes is essential. Some of the core issues that the panel will be exploring: How are leaders ensuring patient and staff safety during the pandemic? Are we doing enough? How are we prioritising patient access to non Covid care and treatment? Are we doing enough to encourage just and learning cultures and staff speaking up for safety? How are we sharing learning and knowledge on safe treatment and care? How are system and professional regulators ensuring that patient safety is a priority? Register
  18. News Article
    NHS Test and Trace chief Baroness Dido Harding will be interviewed by HSJ editor Alastair McLellan at 9am tomorrow as part of HSJ’s virtual provider summit. HSJ’s subscribers working in the NHS or a non-profit organisation can register to attend the summit here. Other speakers will include new Health Education England chief executive Navina Evans and King’s Fund chief executive Richard Murray. The subjects due to be covered include how the NHS will tackle the drive to recover routine care, the service’s workforce challenges and how forthcoming legislation may impact the governance of the service. Full details of the programme can be seen here.
  19. Content Article
    Stu King is is joined by Dr Nisreen Alwan and Prof Susan Michie. Nisreen is Associate Professor in Public Health, University of Southampton. Susan is Director, UCL Centre for Behaviour Change & a committee member of Independent Sage. In this podcast, Nisreen shares her experience of long COVID, what it means and its effects. They look at how both those with long COVID and healthcare workers are affected - how the range of symptoms can be difficult to diagnose, causing anxiety. Plus, the challenge for patients of managing with such unpredictability. Nisreen and Susan discuss the evidence of who is at risk, including young people. And how the public messaging around COVID could do more to alert this group of the risks to their health & wellbeing. Nisreen shares the support available through healthcare and peer support. And Susan shares how indieSAGE will be discussing it in order to advise the government.
  20. News Article
    Across Britain, intensive care nurses and doctors are being pushed to their limits as they try to save lives from coronavirus. During 12-hour shifts in sweltering conditions, they are faced with technical and emotional challenges that many have never faced as they tackle a virus that has swept across the globe in a matter of days, threatening to kill tens of thousands in the UK. Britain has yet to even hit the peak of infections, but intensive care specialists are already asking how long they can keep working relentlessly. “We are trained for and used to dealing with difficult and emotional scenarios, but this is like a major incident that never ends,” says critical care nurse Karin Gerber. As an advanced nurse practitioner in critical care outreach, the 47-year-old sees patients in hospital who are getting sicker and may need to be admitted to intensive care. She says she has never seen anything “at this intensity”. The Royal London Hospital is at the forefront of the capital’s fight against the virus and has created more than 200 extra beds at its Whitechapel site in east London. They are filled with COVID-19 patients. Simon Richards, senior charge nurse at the Royal London’s critical care unit, tells The Independent: “In 20 years as a nurse this situation is by far the worst I have ever seen and totally unexpected, but the team spirit that people have shown has been amazing. “It’s extremely difficult, we are working so hard. The whole team is being pushed to their limit and you do wonder how long can this be sustained for? I wish we could see light at the end of the tunnel.” Read full story Source: The Independent, 24 November 2020
  21. News Article
    Hospital trusts have been put on notice that the challenging storage requirements of the first covid vaccines are likely to mean the vaccination of their staff will have to form the vanguard of the planned roll-out next month due. HSJ reported last week that healthcare staff would share priority with “care home residents and staff” in the vaccine roll-out. However, a letter sent to trust chief executives by NHS England seeks to clarify the situation by stressing that “different vaccines are likely to be better suited to different settings because the vaccines are likely to have different storage, reconstitution and administration requirements”. “Given what we currently know about the first expected vaccine, the imperative is that NHS trusts are ready to start vaccinating from the beginning of December.” Trusts are one of several components of the vaccination programme that includes primary care-run sites, mass vaccination centres, and “roving” visits to those who need them. Local systems and regional teams will decide “the most appropriate combination of models required to deliver the vaccine to their local populations based on local needs” the letter says. However, during the early stages of the roll-out this is likely to be dictated by the vaccine types that become available. Read full story (paywalled) Source: HSJ, 25 November 2020
  22. News Article
    Former health secretary and chair of the Commons health committee Jeremy Hunt has criticised Great Ormond Street Hospital after it was accused of covering up errors that may have led to the death of a toddler. Writing for The Independent, Mr Hunt, who has set up a patient safety charity since leaving government, said it was “depressing” to see how the hospital had responded to the case of Jasmine Hughes, which has now been taken to the Parliamentary Health Service Ombudsman for a new investigation. Mr Hunt said the hospital had chosen to issue a “classic non-apology apology of which any politician would be proud” and added he was left angry over the hospital’s “ridiculous decision” to stop talking to Jasmine’s family and the refusal to apologise for what went wrong. The MP for South West Surrey said the case was symbolic of a wider problem in the health service of a blame culture that prevents openness and transparency around mistakes. Read full story Source: The Independent, 24 November 2020
  23. News Article
    Matt Hancock has called for British people to routinely get tested for the flu, saying covid diagnostic capacity should be kept and used for “everything” once the pandemic dies down. Speaking at the Commons health and social care committee this morning, the health and social care secretary said the nation “must hold on to” the mass diagnostic capacity it has created for coronavirus. Going further, he called for a change in culture to one of “if in doubt, you get a test”, and for a long-term expansion of diagnostics. Mr Hancock said: “Why in Britain do we think it’s acceptable to solider on when you have flu symptoms or a runny nose, and go in [to work] and make everyone ill? “If you have flu-like symptoms you should have a test for it and find out what is wrong with you and stay at home. We are peculiar outliers in soldiering on and going to work and that… culture, that should change.” Read full story (paywalled) Source: HSJ, 24 November 2020
  24. Event
    The NHS is the world’s first health organisation to publish data on avoidable deaths. The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts following the National CQC and NQB guidance, and Department of Health reporting requirements. The conference will also discuss the role of Medical Examiners providing a national system of medical examiners will be introduced to provide much-needed support for bereaved families and patient safety. Further information and to book your place or email nicki@hc-uk.org.uk Follow the conversation on Twitter #CQCDeathsreview We are pleased to offer hub members a 10% discount. Email: info@pslhub.org for the code.
  25. Content Article
    The use of healthcare complaints to improve quality and safety has been limited by a lack of reliable analysis tools and uncertainty about the insights that can be obtained. The Healthcare Complaints Analysis Tool, developed by Alex Gillespie and Tom W. Reader was used to analyse a benchmark national data set, conceptualise a systematic analysis, and identify the added value of complaint data.
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