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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
    Join the webinar to find out how the community sector can implement the National Safety and Quality Mental Health Standards for Community Managed Organisations (NSQMHCMO Standards). The Australian Commission on Safety and Quality in Health Care is releasing a range of practical resources to support CMO service providers, consumers and carers, and accrediting agencies to implement the NSQMHCMO Standards. Accreditation to the NSQMHCMO Standards begins 1 July 2024. Register now to find out about what the Standards mean for you and how you can prepare for the accreditation process. Register
  2. News Article
    Ministers must begin paying compensation to the families of children disabled by the epilepsy drug sodium valproate by next year, a report will say this week. The report’s author, Dr Henrietta Hughes, England’s patient safety commissioner, says valproate is “a bigger scandal than thalidomide, in terms of the numbers of people affected”. She will back calls for financial redress for the thousands of children left physically and mentally disabled. Every month, three babies are still being born who have been exposed to the drug. Speaking before the report’s launch, Hughes, 54, a GP, said the state had failed pregnant women by not telling them about key information regarding the drug’s risks. “These families have already been betrayed, because they weren’t given the right information to be able to make decisions to keep themselves and their family safe,” she said. “There are senior politicians of every stripe who have expressed their sincere sympathy and support for patients who have been harmed. I take the view that people who seek high office need to also accept the responsibility that comes with that high office. “The time for redress is now. The government is responsible. I’ve been asked to give them options for redress and I’ve done that. They have the recommendations, they have the advice, they have everything they need. Get on with it.” Read full story (paywalled) Source: The Times, February 2024
  3. News Article
    Rishi Sunak has admitted the government has failed on a pledge to cut NHS waiting lists in England. The prime minister said the government had "not made enough progress" but that industrial action in the health service "has had an impact". Mr Sunak made the comments in an interview with TalkTV. Cutting NHS waiting lists is one of five priorities Mr Sunak set out in January 2023, along with measures on the economy and illegal immigration. At the time he said "NHS waiting lists will fall and people will get the care they need more quickly" but did not set a timeframe for achieving that. Asked if his government has failed to achieve that pledge, Mr Sunak said: "Yes, we have." The prime minister continued: "What I would say to people is that we've invested record amounts in the NHS - more doctors, more nurses, more scanners. "All these things mean the NHS is doing more than it ever has but industrial action has had an impact." Read full story Source: BBC News, 5 February 2024
  4. News Article
    Hospitals are being pressured to shift their resources to treating patients with less serious conditions to meet a “politically motivated” target, according to multiple senior sources. The pressure appears to be coming through NHS England’s regional teams, with local sources saying they are being told to focus energies on patients in their emergency departments who do not need to be admitted to a ward. These cases are typically faster to deal with, and therefore shifting resources to this cohort could significantly improve performance against the four-hour target. However, experts in emergency care repeatedly warn that admitted patients are the most likely to suffer long waits and harm. The NHS has been tasked with lifting performance against the four-hour target to 76% in 2023-24, but has failed to meet that in any month this year. Performance in December was 69%. Some trust leaders told HSJ they would ignore the instructions, saying they would continue to focus resources on reducing the longest waits. One chief executive in the north of England said: “It’s a complete nonsense and just politically motivated. We’re getting a very clear message to hit 76 per cent which is hugely problematic because it will drive non patient focussed behaviour. We have said ‘no, we are focussing on long waiters and ambulance delays’… in other words doing the right thing for patients.” Read full story (paywalled) Source: HSJ, 5 February 2024
  5. Content Article
    Join Alan Lindemann, an obstetrics-gynecology physician, who shares his insights and real-life experiences, shedding light on the issues surrounding patient care, medical decision-making, and the role of institutions and personal connections in shaping health care outcomes. Discover how the pursuit of quality care can sometimes be obstructed by self-interest and the need to protect reputations. Alan also proposes innovative ideas to enhance transparency and public involvement in health care quality assurance.
  6. News Article
    Worsening health among the under fives in the UK needs to be urgently addressed, experts say. The Academy of Medical Sciences highlights what it says are "major health issues" like infant deaths, obesity and tooth decay. It says society is betraying children and the problems are limiting their future and damaging economic prosperity. The report says: The UK is 30th out of 49 rich countries for infant mortality. One in five children falls short of the expected level of development aged two. One in five is overweight or obese by five. Vaccination targets are being missed for diseases such as measles. One in four is affected by tooth decay by five. One in five women struggles with their mental health during or just after pregnancy. Air pollution is linked to worsening asthma. Rising demand for child mental health services. The report calls for a cross-government vision to be developed to tackle the problems and investment in the child health workforce, including health visitors. Read full story Source: BBC News, 5 February 2024
  7. Content Article
    The Academy of Medical Sciences has released a stark report highlighting wide-ranging evidence of declining health among children under five in the UK and calls on policymakers to take urgent action to address the situation.It warns Government that major health issues like infant mortality, obesity and tooth decay are not only damaging the nation’s youngest citizens and their future, but also its economic prosperity, with the cost of inaction estimated to be at least £16 billion a year. In recent years, progress on child health in the UK has stalled. Infant survival rates are worse than in 60% of similar countries and the number of children living in extreme poverty tripled between 2019 and 2022. Demand for children’s mental health services surge and over a fifth of five-year-old children are overweight or obese, with those living in the most deprived areas twice as likely to be obese than in affluent areas. One-in-four is affected by tooth decay. Vaccination rates have plunged below World Health Organization safety thresholds, threatening outbreaks. Issues such as the COVID-19 pandemic, increased cost of living and climate change compound widespread inequality and are likely to make early years health in the UK even worse. 
  8. News Article
    “What if I told you one of the strongest choices you could make was the choice to ask for help?” says a young, twentysomething woman in a red sweater, before recommending that viewers seek out counselling. This advert, promoted on Instagram and other social media platforms, is just one of many campaigns created by the California-based company BetterHelp, which offers to connect users with online therapists. The need for sophisticated digital alternatives to conventional face-to-face therapy has been well established in recent years. If we go by the latest data for NHS talking therapy services, 1.76 million people were referred for treatment in 2022-23, while 1.22 million actually started working with a therapist in person. While companies like BetterHelp are hoping to address some of the barriers that prevent people from seeking therapy, such as a dearth of trained practitioners in their area, or finding a therapist they can relate to, there is a concerning side to many of these platforms. Namely, what happens to the considerable amounts of deeply sensitive data they gather in the process? Moves are now under way in the UK to look at regulating these apps, and awareness of potential harm is growing. Last year, the UK’s regulator, the Medicines and Healthcare products Regulatory Agency (MHRA) and the National Institute for Health and Care Excellence (Nice), began a three-year project, funded by the charity Wellcome, to explore how best to regulate digital mental health tools in the UK, as well as working with international partners to help drive consensus in digital mental health regulations globally. Holly Coole, senior manager for digital mental health at the MHRA, explains that while data privacy is important, the main focus of the project is to achieve a consensus on the minimum standards for safety for these tools. “We are more focused on the efficacy and safety of these products because that’s our role as a regulator, to make sure that patient safety is at the forefront of any device that is classed as a medical device,” she says. Read full story Source: The Guardian, 4 February 2024
  9. News Article
    Deeply ingrained medical misogyny and racial biases are routinely putting people in need of treatment at risk, the government’s patient safety commissioner in England has warned. Dr Henrietta Hughes was appointed in 2022 in response to a series of scandals in women’s health. She outlined a “huge landscape” of biases in need of levelling, citing examples ranging from neonatal assessment tools and pulse oximeters that work less well for darker skin tones to heart valves, mesh implants and replacement hip joints that were not designed with female patients in mind. Hughes said: “I don’t see this as blaming individual healthcare professionals – doctors and nurses – for getting it wrong. It’s pervasive in the systems we have – the training, the experience, the resources. “Anatomy books are very narrow in their focus. Even the resuscitation models are of pale males – we don’t have female resuscitation models, we don’t have them in darker skin tones. This is deeply ingrained in the way that we assess and listen to patients.” She described the realisation that pulse oximeters, used to measure blood oxygen levels, work less well for darker skin tones as a “real shock to the system” when the problem was highlighted during the pandemic. More recently, the NHS Race and Health Observatory highlighted concerns about neonatal assessments. Bilirubinometers, widely used to assess jaundice in newborn babies, are less reliable for darker skin tones and some guidelines for the assessment of cyanosis (caused by a shortage of blood oxygen) refer to “pink”, “blue” or “pale” skin, without reference to skin changes in minority ethnic babies. The Apgar score, a quick test given to newborns that was rolled out in the 1950s, traditionally includes checking whether a baby is “pink all over”. “Even the names of those conditions – jaundice and cyanosis – suggest a colour. The Apgar score includes P for pink all over,” said Hughes. “There are systemic biases in that if you have a darker skin tone those conditions may not be so apparent.” Read full story Source: The Guardian, 4 February 2024
  10. Content Article
    Set up in January 2023, the Times Health Commission was a year-long projected established to consider the future of health and social care in England in the light of the pandemic, the growing pressure on budgets, the A&E crisis, rising waiting lists, health inequalities, obesity and the ageing population. Its recommendations are intended to be pragmatic, practical, deliverable and able to be potentially taken up by any political party or government, present or future. 
  11. News Article
    Concerns have been raised that patients may not be receiving “vital” safety information after HSJ discovered a high-risk medication was frequently not being dispensed as originally packaged. In 2018, the Medicines and Healthcare Products Regulatory Agency asked pharmacies to dispense valproate-containing medications in their original pack where possible, to ensure packages include safety warnings. It also asked manufacturers to produce smaller pack sizes and add pictorial warnings, while pharmacists were additionally asked to add stickered warnings to the outer box of any valproate-containing medication not dispensed in its original packaging. Yet, data obtained via freedom of information requests to the NHS Business Services Authority revealed that while the proportion and number of valproate-containing items dispensed as split packs – as opposed to whole packs – had decreased over the last five years, split packs still accounted for more than half of items dispensed in 2022-23. Emma Murphy, of campaign group In-Fact, said the figures on split pack dispensing were “quite horrifying” and showed “the system is not working”. She added: “Attitudes have got to change – prescribers, GPs etc need to be proactive and warn women of the risks because this isn’t just a side effect, this is harming real babies. As a mum of five affected children, the consequences of valproate in pregnancy on that baby is devastating.” Alison Fuller, of Epilepsy Action, said the high proportion of split packs being dispensed made it “clear why the change in guidance introduced in October 2023 was necessary”, adding: “The manufacturer’s original full pack always contains all the relevant information, which is why it’s the best option for patient awareness.” Read full story (paywalled) Source: HSJ,
  12. News Article
    The NHS is failing some parents whose children die unexpectedly, a leading paediatrician has told BBC Panorama. About 50 children's deaths in the UK every year are termed as "sudden unexplained death in childhood" (SUDC). Little is known about what causes them. Gavin and Jodie's two-year-old son Addy died unexpectedly in November 2022. BBC Panorama followed the parents over nine months as they searched for answers to why their son died - and whether it could have been prevented. Even after a forensic post-mortem examination, no-one could work out why the little boy went to sleep and never woke up, so his death was categorised as SUDC. When a child dies unexpectedly, a review is held to gather information about what happened. The NHS is required to assign a key worker to help bereaved parents to navigate this process, and provide emotional support. The role of key worker can be taken by a range of practitioners and is often a specialist nurse. However, even though it is a mandatory requirement, a survey carried out by the Association of Child Death Review Professionals (ACDP) found that more than half of NHS areas in England do not have a specialist nurse to visit parents after an unexpected death. "It makes me really angry," says paediatrician Dr Joanna Garstang, the chair of the ACDP, who runs one of the few teams in England that support parents. "Bereaved families after the sudden death of a child are the most vulnerable people. And if we don't put in early support… we're setting these parents up for a lifetime of misery." Read full story Source: BBC News, 5 February 2024
  13. Content Article
    In this animation, the Nursing and Midwifery Council (NMC) look at speaking up and what this means for you as a registered professional.
  14. Content Article
    An innovative approach to managing behaviour in the operating room (OR) using posters with eye symbols has seen positive results. A team of Australian researchers conducted a successful trial to address offensive and impolite remarks within ORs by implementing ‘eye’ signage in surgical rooms. These posters, placed on the walls of an Adelaide orthopaedic hospital’s operating theatre without explanation, effectively reduced poor behaviour among surgical teams. The lead researcher, Professor Cheri Ostroff from the University of South Australia, attributed this outcome to a sense of being ‘watched’, even though the eyes are not real. The three-month experiment targeted a prevalent culture of bullying and misconduct in surgical settings, a problem pervasive not only in healthcare but across various high-stress industries. Professor Ostroff emphasised that besides affecting staff morale and productivity, rude behaviour also has a detrimental impact on patients, particularly in compromising teamwork and communication during surgery, potentially leading to poorer outcomes.
  15. Content Article
    The prevalence of Parkinson’s disease, the second most common neurodegenerative disorder, is increasing worldwide. Characterised clinically by progressive asymmetric slowness of movement, rigidity, tremor, gait disturbance, and a wide range of non-motor symptoms, the aetiology of Parkinson’s disease is multifactorial, involving both genetic and environmental risk factors. Despite the growing public health burden, current treatment strategies are focused solely on symptom management—and disease-modifying treatments are urgently needed to help prevent development of the most disabling refractory symptoms, such as gait and balance difficulties, cognitive impairment and dementia, and speech and swallowing problems. In this three-paper Series, the authors address the current state of knowledge on the epidemiology of Parkinson’s disease, recent advances in our understanding of the pathogenesis of the disease, as well as the latest evidence supporting the optimal medical, surgical, and physical treatment of Parkinson’s disease.
  16. News Article
    Children are being forgotten by the government as they face “disgraceful” waiting times for NHS treatment, Britain’s top paediatric doctor has warned. Dr Camilla Kingdon said children are being failed because their care is not being treated as a priority, despite considerable progress having been made in reducing waiting times for adults. In her final interview as president of the Royal College of Paediatrics and Child Health, she also issued a stark warning over the impact of poverty on young people’s health, lamenting the rise in the number of children being treated for severe lung disease due to damp and poor ventilation in inadequate housing. Many parents cannot afford to be at their dying or sick child’s bedside because of financial pressures – an issue that has grown significantly worse in the past five years, she said. She told The Independent: “Children simply need to be made a priority. We cannot afford to be ignoring this problem.” The latest NHS figures show that the backlog for children’s hospital care has risen again, increasing from 387,000 in August to 412,000 in January, despite the adult waiting list having fallen since October. Read full story Source: The Independent, 31 March 2024
  17. Content Article
    An otherwise healthy patient is taken to the operating room for the removal of a neck mole under monitored sedation. After the patient is given two litres of oxygen through nasal cannula and administered intravenous sedation, an alcohol-based skin preparation is applied to the surgical field. As the surgeon uses electrocautery to coagulate bleeding, a flash occurs, and the surgical drapes ignite. After extinguishing the fire by pouring water on the surgical field, assessment of the patient reveals second-degree burns on the patient’s face. Oxygen from the nasal canula had accelerated the fire and caused the nasal cannula to melt and adhere to the patient’s face. The patient was transferred to the burn unit for care, and ultimately required reconstructive plastic surgery. This case illustrates one type of injury that can be sustained during a surgical fire.  The Joint Commission issues this alert to help healthcare organizations recommit to surgical fire prevention.
  18. Content Article
    As health care specialists, we spend a huge amount of time considering, empathising with, and addressing the needs of the people we want to help. We intimately understand the challenges children and young people face, and how these may impact their health and development long term. Exposed daily to this kind of emotional and physical distress, it can be easy for compassion fatigue to creep in. Our brains work automatically to protect our own mental health, almost desensitising us to the trauma experienced by others. It’s much easier to think of people as statistics, especially when it comes to children and young people. But the more we think in terms of statistics, the more immune to them we become, the more empathy we lose and the less potential there is for an effective, caring health care system that works well for everyone. We need to put the care back into health care.
  19. Content Article
    It’s long been recognised that cross-functional collaboration is essential. Still, stubborn silos that bog down execution, hamper innovation, and slow decision-making are still a common and persistent challenge.  This article highlights three traits that high-performing leaders have in common and strategies for leaders to increase their own lateral agility.
  20. News Article
    Legal costs in Irish medical negligence cases are among the highest in the world, according to a report that says the slow pace of legal actions here is damaging patients and doctors’ mental wellbeing. The average cost of a legal claim for medical negligence in Ireland is almost three times higher than in the UK, and cases take over 50 per cent longer to resolve, the industry report says. Patients and doctors in Ireland are dragged through what can be a brutal process, for longer than necessary, with patients having to wait longer to receive compensation, the report by the Medical Protection Society (MPS) asserts. In the report, the society, which provides indemnity cover for 16,000 doctors and other healthcare professionals in Ireland, compared the length and cost of legal actions here with other jurisdictions in which it operates. A medical negligence claim in Ireland takes 1,462 days on average (four years), 14% longer than in South Africa and 56% longer than in Hong Kong, the UK or Singapore, it found. Two hundred doctors in Ireland were interviewed for the report: 88% said they were worried about the length of time the litigation process was taking and 91% were worried about their mental wellbeing while it was ongoing. Some said they needed professional help, experienced suicidal thoughts, or quit medicine as a result of the claim. “It was horrendous. I had to leave medicine after it,” says one doctor involved in a claim who is quoted in the report. “I developed severe anxiety during the course of the claim and PTSD. I lost my career in medicine and I am devastated about that. I knew I could never go through the same again.” Read full story Source: The Irish Times, 31 January 2024
  21. News Article
    Maternity departments are raising thousands of safety reports every year about delayed inductions of labour, HSJ can reveal. Induction of labour may be used when women are overdue, because their waters have broken, or for other medical reasons to speed up the birth, such as poor growth of the baby. Delaying induction therefore may increase risks for both mothers and babies and the National Institute for Health and Care Excellence says trusts should raise a “red flag event” if it is delayed for more than two hours after admission. Information collected by HSJ from 50 trusts show 4,945 red flags related to delays in induction of labour in 2022-23. HSJ also found 3,109 reports in 2021-22 and 1,807 in 2020-21 across 47 trusts. Meanwhile, there were 1,997 Datix reports mentioning induction of labour in 2022-23 across 59 trusts able to give HSJ figures, in response to Freedom of Information Act requests, compared with 1,690 in 2021-22 and 1,368 in 2020-21. The Care Quality Commission has also raised concerns in inspections that incidents which should have been treated as “red flags” have not always been reported as such. The watchdog has also raised concerns about a lack of board-level oversight of maternity safety incidents and a need for clearer guidance for staff on reporting processes. Read full story (paywalled) Source: HSJ, 2 April 2024
  22. News Article
    Jason Watkins, a British actor, has urged A&E units to look again at procedures surrounding infants as he has channels his anger at his young daughter’s death from sepsis into trying to “improve the system”. The actor said that his fury at the death of Maude aged two on New Year’s Day 2011 led him to smash up his shower. “It wasn’t anger at any individual, it was anger at fate. Why should we deserve this?” he told Andy Coulson’s Crisis What Crisis? podcast. “You feel really vulnerable and there’s a sort of rage against that. And there are all these different ways of resolving and wrestling out of this horrible dark pit that you’re in." He now campaigns for the UK Sepsis Trust. “I was never angry at any individual,” he said. “My anger was fuelled into trying to work out better ways of dealing with sepsis, or even more than that, the way that we look at infants in A&E. Because you know, it’s a funding issue, it’s an organisational issue. It’s another conversation. “Because I had identified that there wasn’t an individual at fault in the hospital, it has to be the system. So we’ve got to improve it. My anger is fuelled into that. There’s no bitterness. Nobody made a technical mistake, it’s just nobody really thought of the possibilities of what could be happening. “For me the whole of looking at infants arriving at A&E needs to be looked at again. Because if I say that Maude died twelve years ago, and that the ombudsman report about sepsis a couple of months ago said that nothing had changed about sepsis, now, that was like a body-blow, that makes me feel sick even thinking about it now, because we’ve worked so hard over that time.” Read full story Source: The Times, 1 February 2024
  23. News Article
    Deaths from cancer in the UK are set to rise by more than 50% in the next 26 years, stark new estimates suggest. Experts from the International Agency for Research on Cancer (IARC) and the World Health Organization (WHO) have found there were 454,954 new cases of cancer in the UK in 2022 and warned this is expected to rise to 624,582 by 2050. In 2022, 181,807 people died in Britain from cancer, but researchers warned this is expected to rise to 279,004 by 2050 – a 53% increase. The estimates suggest the rising rates of cancer will be driven by the UK’s growing and ageing population. However, researchers have also called for new policies to tackle levels of smoking, unhealthy diets, obesity and alcohol to help lower the expected surge in cases. The study examined cancer data from 115 different countries and estimated global cases would rise by 77 per cent, from 20 million in 2022 to 35 million in 2050. The organisations estimate that cancer deaths around the world will almost double from 9.7 million to 18.5 million in that time. Dr Panagiota Mitrou, director of research, policy and innovation at the World Cancer Research Fund, said the new estimates “show the increased burden that cancer will have in the years to come”. “UK governments’ failure to prioritise prevention and address key cancer risk factors like smoking, unhealthy diets, obesity, alcohol and physical inactivity has in part widened health inequalities,” she added. Read full story Source: The Independent, 1 February 2024
  24. News Article
    Online services for GPs across Surrey leave many patients feeling "helpless and lost", a new report says. Healthwatch Surrey said some patients felt "defeated" by online systems and that issues were worse in certain groups. This included people with English as a second language and those less confident with technology. Online services include booking appointments, requesting repeat prescriptions and viewing test results. Healthwatch Surrey, which gathers the views of local people on health and social care services in the county, said: "Confusion around the appointment booking process and a perception that appointments are hard, or even impossible, to book online is the issue people tell us most about." One Epsom and Ewell resident was asked by their surgery to book a blood test online. They told Healthwatch: "I tried but I couldn't understand how to do it and so I called back. "I'm in my 80s and I try to be as independent as I can, but some of these processes defeat me." Sam Botsford, contract manager at Healthwatch Surrey, said communication was key in ensuring patients knew how to use online services. She said: "People feel they're being pushed online, and that spans a range of different demographics. "It's really important for practices to identify the needs of their patients and how they can best meet those." Read full story Source: BBC News, 2 February 2024
  25. Content Article
    The aim of this study was to investigate the incident reporting process (IR1s), to calculate the costs of reporting incidents in this context and to gain an indication of how economic the process was and whether it could be improved to yield better outcomes.
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