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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Emergency surgical patients are at high risk for harm because of errors in care. Quality improvement methods that involve process redesign, such as “Lean,” appear to improve service reliability and efficiency in healthcare. This study found that lean can substantially and simultaneously improve compliance with a bundle of safety related processes. Given the interconnected nature of hospital care, this strategy might not translate into improvements in safety outcomes unless a system-wide approach is adopted to remove barriers to change.
  2. News Article
    In 2023-2024, the US News Best Hospitals ranked hospitals in the USA in 15 adult specialties as well as recognised hospitals by state, metro and regional areas for their work in 21 more widely performed procedures and conditions. Of the nearly 5,000 hospitals analyzed and 30,000 physicians surveyed, only 164 hospitals ranked in at least one of the specialties. Read full story Source: US News
  3. Content Article
    Expecting paramedics to wade through shared care records is unsafe and inefficient. In an emergency, access to essential information has to be easy and fast, writes Claire Jones from NHS England South West. Whilst ambulance services may need access to the entire longitudinal record, it is imperative that in those first vital minutes of an emergency they have the most pertinent and relevant data at their fingertips. In such cases, information sharing can be a matter of life or death. We should make it as easy as possible for emergency care providers to access and view relevant information about the person in their care.
  4. Content Article
    ECRI's Top 10 Health Technology Hazards for 2024 list identifies the potential sources of danger ECRI believe warrant the greatest attention this year and offers practical recommendations for reducing risks. Since its creation in 2008, this list has supported hospitals, health systems, ambulatory surgery centres and manufacturers in addressing risks that can impact patients and staff. 
  5. Content Article
    This National Patient Safety Alert has been issued by the NHS England National Patient Safety Team, co-badged by the Association of Anaesthetists, Royal College of Anaesthetists and the Safe Anaesthesia Liaison Group, instructing all relevant NHS funded providers to transition to NRFit™ connectors for all intrathecal and epidural procedures, and delivery of regional blocks. Transition should be completed by 31 January 2025.
  6. Content Article
    This NICE guideline covers the recognition, diagnosis and early management of suspected sepsis. It includes recommendations on recognition and early assessment, initial treatment, escalating care, finding the source of infection, early monitoring, information and support, and training and education.   In January 2024,, the evidence was reviewed and NICE has made new recommendations on risk evaluation and management of suspected sepsis for people aged 16 or over who are not and have not recently been pregnant, in mental health, ambulance and acute hospital settings. This covers the population and settings in which the national early warning score (NEWS2) applies.
  7. News Article
    People who are severely ill with suspected sepsis should promptly be given life-saving access to antibiotics to prevent unnecessary deaths, according to updated guidance from the National Institute for Health and Care Excellence (NICE.) The guidelines state that the national early warning score should be used to assess people with suspected sepsis aged 16 and over, who are not and have not recently been pregnant, and are in an acute hospital setting or ambulance. The updated guidance also recommends that doctors are more considerate as to who is given antibiotics, in order to reduce the risk of antibiotic resistance in people being prescribed them for less severe cases of sepsis. With the update, NICE says that more people will be categorised at a lower risk level where a sepsis diagnosis should be confirmed before being given antibiotics. Prof Jonathan Benger, Nice’s chief medical officer, said: “This useful and usable guidance will help ensure antibiotics are targeted to those at the greatest risk of severe sepsis, so they get rapid and effective treatment. It also supports clinicians to make informed, balanced decisions when prescribing antibiotics. “We know that sepsis can be difficult to diagnose so it is vital there is clear guidance on the updated [national early warning score] so it can be used to identify illness, ensure people receive the right treatment in the right clinical setting and save lives." Read full story Source: The Guardian, 31 January 2024
  8. News Article
    New digital prescriptions mean NHS App users in England can now collect medication from a pharmacy without having to visit a GP or health centre. The usual paper slip given by doctors has been replaced by an in-app barcode, which can be scanned at any pharmacy. Users can already request repeat prescriptions on the app - and every digital order fulfilled will save the GP three minutes, NHS Digital says. It comes after a trial last year, involving more than a million users. Patients can use the app to check what medicines they have been prescribed, and when. Anyone who has a nominated pharmacy can continue to collect medication without a paper prescription or barcode, as the details are sent to their pharmacy electronically. Read full story Source: BBC News, 30 January 2024
  9. Content Article
    One way to understand the links between unwanted events, conditions and interventions is via causal loop diagrams. These represent how situations perpetuate in 'causal loops'. They are depicted as words and phrases for events and conditions, and arrows with a plus or minus sign to indicate the direction of causal influence. Causal loop diagrams can assist a conversation via the gradual building of each loop. They can otherwise represent data from research and practice.  Steven Shorrock illustrate the progressive build of a causal loop diagram concerning reactions to unwanted events, including fixes that fail, based on practice and research. This might be useful to professionals seeking to understand why unwanted events continue to occur despite, or because of, interventions. The diagram is not ‘complete’ and would be drawn differently for different purposes, contexts and situations.
  10. News Article
    Unregulated healthcare workers are a risk to the most vulnerable patients, a former victim’s commissioner has warned after The Independent and Sky News uncovered a “horrifying” sexual abuse scandal within NHS mental health services. Dame Vera Baird called for a formal framework for healthcare assistants and support workers, who do not have a mandatory professional register like doctors and nurses and can “come in and go out from one hospital to another” without the same thorough checks. Dame Vera told The Independent that the setup did not lead to a “very safe way of working” because healthcare assistants are “in an environment where they are responsible for vulnerable people”. “If there has been abuse from mental health care assistants who are also agency staff who are coming in and going out from one hospital to another, that needs to be looked at,” she said. “This is not a very safe way of working. Some kind of framework around agency staff seems to be very important [to have].” She warned that sexual predators may go into mental health services and work in units where patients can be “highly sexualised”, prompting a “dreadful combination”. Read full story Source: The Independent, 30 January 2024
  11. News Article
    Health service dentistry in Northern Ireland could be caught in a "death spiral" without radical action, more than 700 dentists have warned. They say a combination of factors could make the service unsustainable. These include a potential ban on dental amalgam metals used in fillings, budget pressures and a "financially unviable contractual framework". The dentists have called on the Department of Health (DoH) "to show leadership and take action now". A DoH spokesperson said the department "valued the important role" of dentists and was "aware of the ongoing pressures on dental practices". In an open letter to Peter May, the top civil servant at the DoH, dentists from the British Dental Association (BDA) Northern Ireland warned that services were under "intolerable pressure". The letter said: "Despite clear evidence and repeated warnings issued by the BDA about the death spiral health service dentistry in Northern Ireland appears to be in, we have seen inaction from the authorities." The dentists added that a move away from health service dentistry was "well and truly underway" and dentists would "be increasingly driven out of health service dentistry to keep their practices afloat". Read full story Source: BBC News, 30 January 2024
  12. Event
    ECRI's Top 10 Health Technology Hazards for 2024 list will identify the potential sources of danger we believe warrant the greatest attention this year and offer practical recommendations for reducing risks. Since its creation in 2008, this list has supported hospitals, health systems, ambulatory surgery centres, and manufacturers in addressing risks that can impact patients and staff, including specific calls to action for the industry. Join Device Evaluation leaders as they reveal the top concern on our list and its larger impact on healthcare. Speakers: Jason Launders, Director of Operations, Device Evaluation, ECRI Rob Schluth, Principal Project Officer I, Device Evaluation Priyanka Shah, Sr. Project Officer, Device Evaluation Register
  13. Event
    This webinar will cover NIHR research that could help improve the safety and quality of maternity care. Speakers will present actionable evidence that attendees can implement in their own practice. Presentations will be followed by a Q&A session, giving you a unique opportunity to quiz the researchers on how you could act on this research, and reflect on potential barriers and facilitators. The webinar will cover: women’s experiences of labour induction the 7 features of safe care in maternity units the role of hospital boards in improving maternity care. Register
  14. Event
    If you work in primary care or primary care research, this one-hour NIHR Evidence webinar is for you. This webinar will cover NIHR research that could help reduce antibiotic prescribing in primary care. Speakers will present actionable evidence on antibiotic stewardship, and safe and effective prescribing. Presentations will be followed by a Q&A session, giving you a unique opportunity to quiz the researchers on how this research could be implemented at your organisation and reflect on potential barriers and facilitators. The webinar will cover: making decisions about who is in most need of antibiotics if antibiotics are needed for children with chest infections how digital tools can help reduce antibiotic prescribing. Register
  15. Content Article
    The Department of Health and Social Care (DHSC) and Health Services Safety Investigations Body.(HSSIB) share the common objective to improve patient safety. To achieve this, HSSIB and DHSC will work together in recognition of each other’s roles and areas of expertise, providing an effective environment for HSSIB to achieve its objectives through the promotion of partnership and trust, and ensuring that HSSIB also supports the strategic aims and objective of DHSC and wider government as a whole.
  16. Content Article
    This document from the Department of Health and Social Care (DHSC) sets out how health and care systems should work together to support discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults. It sets out best practice on: how NHS bodies and local authorities should work closely together to support the discharge process and ensure the right support in the community, and provides clarity in relation to responsibilities  patient and carer involvement in discharge planning.
  17. Content Article
    Panorama investigates the crisis in maternity care that is putting women and babies at risk. Whistleblowers at a trust in Gloucestershire tell reporter Michael Buchanan about the deaths of mothers and babies, the dangers of understaffing and a culture that they say has failed to learn from mistakes. The regulator, the Care Quality Commission, has said that maternity services at the trust are inadequate, and Panorama has calculated that maternal deaths there are almost double the national average. The trust says that it's deeply sorry for failings in its care and that it's made improvements to its maternity services.
  18. Content Article
    Thomas Ithell was aged 77 at the time of his death on 20 November 2022. He was diagnosed with prostate cancer in September 2017 and biopsies revealed bilateral adenocarcinoma of the prostate. He underwent radiotherapy in 2018 and hormone deprivation treatment. From April 2021 onwards his PSA levels increased periodically. In October 2021 his level was 5.5ng/ml having been 1.5ng/m lin April 2021 and 2.7ng/m in July 2021 indicating a recurrence of the cancer and likely incurable. Thomas Ithell was reluctant to undergo further hormone treatment as he found tolerating the side effects difficult. He did not then have his PSA levels tested after November 2021 and was not reviewed at all due to becoming missed to follow up. After he had been seen by the nurse practitioner on 5 November 2021, the letter written by the nurse practitioner for advice from the consultant did not reach the consultant. He was reviewed by a consultant on 22 October 2022 after an urgent suspected cancer GP referral following routine set of blood tests in September 2022, some 10 months later. Mr Ithell died in hospital on 20 November 2022 having been admitted with shortness of breath, the malignancy having caused his death.
  19. News Article
    Serious concerns about maternity services at an NHS trust have been revealed by BBC Panorama. Midwives say a poor culture and staff shortages at Gloucestershire Hospitals NHS Trust have led to baby deaths that could have been avoided. A newborn baby died after the trust failed to take action against two staff, the BBC has been told. The trust says it is sorry for its failings and is determined to learn when things go wrong. Concerns about two staff members, both midwives, had been raised by colleagues at the Cheltenham Birth Centre after another baby died 11 months earlier. The birth centre allowed women with low-risk pregnancies the choice of giving birth there under the care of midwives - there were no emergency facilities in the centre. In the event of complications, women should have been transferred to the Gloucestershire Royal Hospital, which is part of the same trust and about a 30-minute drive away. But on both occasions, the two midwives did not get their patients transferred quickly enough. The two midwives on duty for both deaths are now being investigated by their regulator, the Nursing and Midwifery Council. Read full story Source: BBC News, 29 January 2024
  20. News Article
    Physician associates have attempted to illegally prescribe drugs at dozens of NHS trusts and missed life-threatening diagnoses, a dossier claims. Doctors working across the country claim patients’ lives have been put at risk by physician associates (PAs) who they say have failed to respond appropriately to medical emergencies – alleging more than 70 instances of patient harm and “near misses”. The Telegraph has seen responses from more than 600 doctors to a survey on PAs run by Doctors’ Association UK (DAUK), a campaign group. The data suggest that at over half of England’s hospital trusts, doctors are being replaced by PAs on the rota, despite associates only completing a two-year postgraduate course and having no legal right to prescribe. A spokesperson from the Department of Health said their role “is to support doctors, not replace them”. The Telegraph has interviewed more than a dozen surveyed doctors, as well as other clinicians worried about patient safety. At Dudley Group NHS Trust, one junior doctor said a PA had missed an “obvious heart attack” on an ECG, having “just signed it as if it was normal”. A clinician in primary care alleged PAs repeatedly misdiagnosed a patient’s metastatic cancer as muscle ache – despite blood results that were “tantamount” to a cancer diagnosis. They said: “The patient could have been saved eight months of pain; their life could have been prolonged.” Read full story (paywalled) Source: The Telegraph, 27 January 2024
  21. News Article
    A prostate cancer patient went a year without a check-up because his referral to a consultant was lost. An inquest into the death of Thomas Ithell also heard that when the error was spotted it was not recorded because staff at Wrexham Maelor Hospital were too busy. The 77-year-old from Wrexham died in November 2022 after being admitted to hospital with shortness of breath. Assistant Coroner for North Wales East and Central, Kate Robertson, has submitted a Prevention of Future Deaths report to the health board in relation to Mr Ithell's case. As well as concerns over the lack of an investigation, she also questioned how the patient's follow-up appointment was missed. "There have been no assurances as to what, if any, changes and learning have been identified other than a tracking system for PSA monitoring," she wrote, referring to a type of blood test that helps diagnose prostate cancer. She was also concerned to learn that the hospital's Datix system - used for reporting incidents such as Mr Ithell's - had been described as "not user-friendly". Time constraints also sometimes prevented staff from completing these reports, thereby failing to trigger subsequent investigations by the board, the assistant coroner added. "I remain incredibly concerned that where matters are not raised in accordance with internal health board processes that assurances given to me in previous Prevention of Future Deaths reports cannot be supported," Ms Robertson added. Read full story Source: BBC News, 27 January 2024
  22. Content Article
    In his IHI Forum 2023 address, IHI President Emeritus and Senior Fellow Don Berwick explained why competitiveness does not lead to the best possible care. He shared his view on the limitations of free-market healthcare and his personal experience of how kindness can support our efforts to improve care.
  23. Content Article
    Health-compromising behaviours such as cigarette smoking and poor dietary habits are difficult to change. Most social-cognitive theories assume that the intention to change is the best predictor of actual change, but people often do not behave in accordance with their intentions. Unforeseen barriers emerge, or people give in to temptations. Therefore, intentions should be supplemented by more proximal predictors that might facilitate the translation of intentions into action. Some self-regulatory mediators have been identified, such as perceived self-efficacy and strategic planning. They help to bridge the intention-behavior gap. The Health Action Process Approach (HAPA) suggests a distinction between (1) a preintentional motivation process that leads to a behavioural intention and (2) a postintentional volition process that facilitates the adoption and maintenance of health behaviours. In this article, two studies are reported that examine mediators between intentions and two behaviours. One behaviour is smoking reduction in young adults, the other is dietary restraint in overweight patients with chronic disease. A structural equation model, specified in terms of the HAPA, was in line with both data sets but it explained more variance of dietary behaviours among middle-aged or older individuals with a health condition whereas variance of smoking reduction in healthy young adults was less well accounted for. The findings contribute to the elucidation of psychological mechanisms in health behaviour change and point to the particular role of mediator variables.
  24. Content Article
    Young mother and former GB youth swimmer, Alexis, agrees to enter NHS England psychiatric care following a family tragedy. She could never imagine that her three-day admission will turn into a three-year ordeal. Then undiagnosed with autism, and often the subject of 24-hour surveillance as well as long periods in solitary confinement, Alexis descends to the darkest reaches of locked-in, psychiatric care. There, she encounters the kind of threat she never could have imagined in a secure mental health hospital. In a bid to break free, Alexis plots a daring escape. This series discusses rape and sexual assault.
  25. News Article
    Tens of thousands of sexual assaults and incidents have been reported in NHS-run mental health hospitals as a “national scandal” of sexual abuse of patients on psychiatric wards can be revealed. Almost 20,000 reports of sexual incidents in the last five years have been made in more than half of NHS mental health trusts, according to exclusive data uncovered in a joint investigation and podcast by The Independent and Sky News. The shocking findings, triggered by one woman’s dramatic story of escape following a sexual assault in hospital revealed in a podcast, Patient 11, show NHS trusts are failing to report the majority of incidents to the police and are not meeting vital standards designed to protect the UK’s most vulnerable patients from sexual harm. Throughout the 18-month investigation, multiple patients and their families spoke to The Independent about their stories of sexual assault and abuse while locked in mental health units. Dr Lade Smith, president of the Royal College of Psychiatrists, called the findings “horrendous”, while shadow health secretary Wes Streeting said it was a “wake-up call” for the government. Dr Smith told The Independent: “There is no place for sexual violence in society, which has a profound and long-lasting negative impact on people’s lives. Today’s horrendous findings show that there is still much to do to make sure that patients and staff in mental health trusts are protected from sexual harms at all times. “It is deeply troubling to see that so many incidents in mental health settings go unreported.” Read full story Source: The Independent, 29 January 2024
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