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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Next week’s launch of the ‘Wayfinder’ waiting time information service on the NHS App will give patients “disingenuous” and “misleading” information about how long they can expect to wait for care, senior figures close to the project have warned. Briefing documents seen by HSJ show the figure displayed to patients will be a mean average of wait times taken from the Waiting List Minimum Data Set and the My Planned Care site. However, it was originally intended that the metric displayed would be the time waited by 92% of relevant patients. This is more commonly known as the “9 out of 10” measure. Mean waits are likely to be about “half the typical waiting time” measured under the 9 out of 10 metric, according to the waiting list experts consulted by HSJ. Ahead of The Wayfinder service’s launch on Tuesday, NHS trusts and integrated care boards have been sent comprehensive information on how to publicise it, including a “lines to take” briefing in case of media inquiries. This mentions the use of an “average” time but does not provider any justification for this approach. HSJ’s source said the mean average metric was “the worst one to choose” as it would be providing patients with “disingenuous” information that will leave them disappointed. They added that the 92nd percentile metric would be a “far more realistic” measure “for a greater number of people”. They concluded that “using an average” would create false expectations “because in reality nobody will be seen in the amount of time it is saying on the app.” Read full story (paywalled) Source: HSJ, 26 January 2024
  2. News Article
    Rebecca McLellan, a trainee paramedic, pursuing the job she had dreamed of as a child, took her own life at the age of 24. Amid the devastation felt by her loved ones, serious questions have now emerged about the standard of care she received at Norfolk and Suffolk NHS Foundation Trust (NSFT). In notes recorded before her death last November, McLellan said that Norfolk and Suffolk NHS Foundation Trust (NSFT) had “abandoned” her in a time of need. An internal investigation has now been launched by the mental health trust, which has been dogged by safety concerns for more than a decade. Relatives of McLellan, who lived in Ipswich, Suffolk, and was being treated for bipolar disorder, are among hundreds of bereaved families who believe their loved ones were failed under the care of the trust. Her mother, Natalie McLellan, 48, said it was clear that some of her daughter’s feelings of helplessness in her final months were “shaped by their inadequacy”. “She was somebody that had it all,” said Natalie. “She had a supportive family, she had a nice flat, she had a nice car, she was doing exactly what she wanted to do in life. She had a voice, she was able to speak and advocate for herself as a medical professional. If she can’t get help, what the hell hope is there for anybody else? Recent months have seen calls for a public inquiry and criminal investigation into NSFT after bosses last year admitted to losing count of the number of patients that had died on its books. Campaigners describe the mismanagement of mortality figures as “the biggest deaths crisis in the history of the NHS”. The Times has spoken to trust staff, bereaved relatives and MPs who say that despite repeated promises of improved care the trust’s overstretched services remain unsafe and require urgent reform. Read full story (paywalled) Source: The Times, 26 January 2024
  3. News Article
    Hospitals in England are being hit with disruptions to patients’ care more than 100 times every week because of fires, leaks and problems created by outdated buildings, NHS figures reveal. There have been 27,545 “clinical service incidents” over the past five years – an average of 106 a week – data compiled by the House of Commons library shows. They are incidents the NHS says were “caused by estates and infrastructure failure related to critical infrastructure risk” and are linked to the service’s massive backlog of maintenance, the bill for which has soared to £11.6bn. All the incidents led to “clinical services being delayed, cancelled or otherwise interfered with” for at least five patients for a minimum of 30 minutes. That means the 27,545 incidents between 2018-19 and 2022-23 disrupted the care of at least 137,725 patients, according to an analysis of NHS data by the Commons library commissioned by Ed Davey, the leader of the Liberal Democrats. “These findings are shocking but sadly not surprising, given the dilapidated, and in some cases dangerous, state of so many NHS facilities,” said Saffron Cordery, the deputy chief executive of NHS Providers, which represents health service trusts. The “unacceptable impact on patients” should spur ministers into increasing the NHS’s capital budget so trusts can urgently overhaul their estates, she said. Read full story Source: The Guardian, 26 January 2024
  4. Event
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    Kennedys' healthcare team are delighted to invite you to the second session of our annual healthcare seminar programme 2024, which will be held both in-person and virtually on Wednesday 28 February. Guest speaker: John Mead, Technical Claims Director, NHS Resolution John Mead studied at London University and then joined the insurance industry, where he dealt with a wide range of claims against local authorities, some of which reached the Court of Appeal and House of Lords. He moved to NHS Resolution in 1999 and has led the Technical Claims Unit since its creation in 2000, in which he is responsible for overseeing large, complex and potentially repercussive claims against NHS bodies and other scheme members. John is a Fellow of the Chartered Insurance Institute and an accredited mediator. He is an editor for the Journal of Patient Safety and Risk Management, and has contributed to a number of books, most recently Lessons from Medico-Legal Cases in Obstetrics and Gynaecology (2022). This session will be chaired by Kennedys' Partner and Global Head of Healthcare Christopher Malla. Register
  5. Content Article
    Traditionally, recommendations regarding responding to medical errors focused mostly on whether to disclose mistakes to patients. Over time, empirical research, ethical analyses and stakeholder engagement began to inform expectations — which are now embodied in communication and resolution programmes (CRPs) — for how healthcare professionals and organisations should respond not just to errors but any time patients have been harmed by medical care (adverse events). CRPs require several steps: quickly detecting adverse events, communicating openly and empathetically with patients and families about the event, apologising and taking responsibility for errors, analysing events and redesigning processes to prevent recurrences, supporting patients and clinicians, and proactively working with patients toward reconciliation. In this modern ethical paradigm, any time harm occurs, clinicians and health care organisations are accountable for minimising suffering and promoting learning. However, implementing this ethical paradigm is challenging, especially when the harm was due to an error.
  6. Content Article
    Operating room black boxes are a way to capture video, audio, and other data in real time to prevent and analyse errors. This article from Campbell et al. presents the results of two studies on operating room staff's perspectives of black boxes. Quality improvement, patient safety, and objective case review were seen as the greatest potential benefits, while decreased psychological safety and loss of privacy (both staff and patient) were the most common concerns.
  7. Content Article
    The National Coronial Information System (NCIS) is an online repository of coronial data from Australia and New Zealand.
  8. Content Article
    This is the video recording of a House of Lords debate on the delivery of maternity services in England, put forward by Baroness Taylor of Bolton.
  9. Content Article
    In 2023, the Royal College of Surgeons of England surveyed the UK surgical workforce to identify the key challenges facing surgical teams and to inform workforce planning. Respondents included consultants, surgeons in training, Specialist, Associate Specialist and Specialty (SAS) surgeons, Locally Employed Doctors in surgery (LEDs) and members of the extended surgical team (EST).   Advancing the Surgical Workforce reveals a number of interesting insights and paints a picture of a surgical workforce working long hours and in stressful environments. Too many staff are trying to navigate a system which frustrates the delivery of surgical services rather than enabling them. Surgical trainees in particular are increasingly being affected by these pressures. 
  10. News Article
    Diabetes patients have told the BBC they are struggling without what they have called a "wonder drug". Experts estimate about 400,000 people with Type 2 diabetes could have been affected by a national supply shortage caused by rising demand. The new generation of medicines - GLP-1 receptor agonists - mimic a hormone that not only controls blood sugar levels but also suppresses appetite. The government said it was trying to help resolve the supply chain issues. NHS England has issued a National Patient Safety Alert for the drugs. The NHS alerts require action to be taken by healthcare providers to reduce the risk of death or disability. The diabetes medicines in short supply are Ozempic, Trulicity, Victoza, Byetta, and Bydureon. They work via injections instead of tablets. The group of medicines has been used by the NHS for diabetes for around a decade but in recent years there has been a growth in private clinics prescribing the same drugs for weight loss for people who do not have diabetes, pushing up demand. Novo Nordisk, which manufactures Ozempic and Victoza, told the BBC it was experiencing shortages of its medicines for people in the UK with Type 2 diabetes due to "unprecedented levels of demand". Read full story Source: BBC News, 26 January 2024 Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy or in hospital? To help us understand how these issues impact the lives of patients and families, please share your experience and insights in our hub community thread on the topic here or drop a comment below. You'll need to register with the hub first, its free and easy to do.
  11. News Article
    Paramedics are "watching their patients die in the back of ambulances because they can't get them into A&E", according to the health union, Unison. It was commenting on data showing 2,750 hours were lost by ambulance crews waiting to hand over patients at Hull Royal Infirmary in October 2023. One crew was stuck outside A&E for 10 hours and 27 minutes. Hull University Teaching Hospitals said it was "confident" a new urgent treatment centre on the hospital site would "improve overall waiting times" and lost ambulance hours had "reduced notably" this month. The figures, obtained by the BBC through a freedom of information request, showed on 9 October 2023 ambulance crews lost 144 hours and 18 minutes, the equivalent to one crew being out of action for six full days and nights. Megan Ollerhead, Unison's ambulance lead in Yorkshire, said paramedics were "literally watching their patients die in the back of these ambulances because they can't get into A and E." "I talk to a lot of the people who receive the 999 calls in the control rooms and they're just listening to people begging for ambulances and they know there are none to send." Read full story Source: BBC News, 26 January 2024
  12. Content Article
    Poor health literacy can inhibit patient or caregiver understanding of care instructions and threaten patient safety. This cross-sectional study from Selzer et al. of medically complex children treated at one academic hospital in Austria reveals that despite high levels of satisfaction with care, many caregivers do not understand medication management instructions at discharge. Misunderstandings were more likely to occur with higher numbers and/or new prescriptions, poor medication-related communication, and language or literacy barriers.
  13. Content Article
    A new MIT study identifies six systemic factors contributing to patient hazards in laboratory diagnostics tests. By viewing the diagnostic laboratory data ecosystem as an integrated system, MIT researchers have identified specific changes that can lead to safer behaviours for healthcare workers and healthier outcomes for patients.
  14. Content Article
    Sickness absence in the English NHS in 2022 was 5.6% – higher than the 4.3% rate three years earlier pre-covid, and totalling some 27 million days sickness absence. Moreover, 54.5% of staff reported they had gone into work in the previous three months despite not feeling well enough to perform their duties. This is a challenge for staff, managers, employers and occupational health services. Sickness absence measured and reported accurately can help identify trends that may assist with both understanding individual causes and preventing or mitigating sickness absence patterns by addressing their root causes. The NHS, along with many other public sector organisations, however, relies on a system of sickness absence measurement called the “Bradford Factor” which some suggest is counterproductive, without research underpinning and needs to be replaced. The Bradford Factor is a system which creates individual level, “trigger points” at which line managers consider investigation which may lead to disciplinary action to supposedly prompt improved attendance and referral to occupational health. The NHS’s over reliance on the Bradford Factor is potentially discriminatory and highlights the urgent need for a shift in how the service manages sickness absence, writes Roger Klein in this HSJ article.
  15. Content Article
    Hundreds of doctors - led by campaign group Long Covid Doctors for Action - are planning to sue the NHS over claims that inadequate PPE provision has left them with Long Covid. One of those, Dr Nathalie MacDermott, joins Women's Health host Emma Barnett to discuss it. Listen from 2:40
  16. Event
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    Join NHS Confederation as they present the draft guiding principles ahead of publication of the NHS patient safety strategy and seek feedback from the group. The NHS patient safety strategy aims to create supportive safety cultures that focus on learning and improvement. In this session we will introduce the Primary Care patient safety strategy with a focus on the Patient Safety Incident Response Framework (PSIRF) - a core element that outlines best practice for learning from safety events. In 2022 the national patient safety team co-ordinated a primary care working group consisting of clinicians, PCNs, GP Federations and ICBs to develop a set of guiding principles for applying PSIRF within general practice. In this session we will present the draft guiding principles ahead of publication, seek feedback from the group regarding the proposed approach, and explore future opportunities to work together to further develop national strategy. Register
  17. Content Article
    Medicine shortages in the UK have been a regular feature on newspaper front pages in recent years. As a doctor on the frontline, Ammad Butt sees how this instability in our medicine supply chain is playing out on the ground. Ammad works in a large city hospital and is used to meeting disgruntled patients who have had to wait hours in clinic to receive treatment. But just imagine their concern when he has to explain to them that the medication they usually took to treat them with is not available, and that they will have to take an alternative instead or stay in hospital for even longer as a result. In the past year, Ammad has routinely seen patients having to go without medication for common conditions such as attention deficit hyperactivity disorder (ADHD), diabetes and even acne that would otherwise be easily managed, or being forced to take alternatives that are less appropriate. And new EU plans for its members to work together to stockpile key medicines will only worsen shortages in the UK. Patients tell Ammad they feel others are receiving better treatment than they are. And they are right, in some ways. Healthcare professionals are being put in a difficult situation having to explain why they are making compromises in their care. It all adds to the sense among patients and healthcare professionals alike that the health service is not working for the most vulnerable. Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy?  Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy or in hospital? To help us understand how these issues impact the lives of patients and families, please share your experience and insights in our hub community thread on the topic here or drop a comment below. You'll need to register with the hub first, its free and easy to do. 
  18. News Article
    The EU is to stockpile key medicines that will worsen the record drug shortages in the UK, with experts warning that the country could be left “behind in the queue”. The EU is seeking to safeguard its supplies by switching to a system in which its 27 members work together to secure reliable supplies of 200 commonly used medications, such as antibiotics, painkillers and vaccines. But the bloc’s move to insulate itself from growing drug shortages threatens to exacerbate the increasing scarcity of medicines facing the NHS, posing serious problems for doctors. “Europe is securing access to key drugs and vaccines as a single region, with huge influence and buying power. As a result of Brexit the UK is now isolated from this system, so our drug supplies could be at risk in the future,” said Dr Andrew Hill, an expert on the pharmaceutical trade. Britain is experiencing a record level of drug shortages, with more than 100 – including treatments for cancer, type 2 diabetes and motor neurone disease – scarce or impossible to obtain. Mark Dayan, the Brexit programme lead at the Nuffield Trust health thinktank, said the EU’s decision to act as a buying cartel could seriously disadvantage Britain. “There is a real risk that measures in such a large neighbour, which is now a separate market due to Brexit, will leave the UK behind in the queue when shortages strike,” Dayan said. It also has an initiative for member states to transfer stocks of medicine to cover shortages in others. These measures could shut UK purchasers out in certain scenarios. “This would risk worsening shortages from a starting point where they are already exceptionally severe for the UK and other countries, with a mounting impact in terms of costs and wasted time for the NHS, and in terms of patients struggling to get what their doctors have said they need.” Read full story Source: The Guardian, 25 January 2024 Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy or in hospital? To help us understand how these issues impact the lives of patients and families, please share your experience and insights in our hub community thread on the topic here or drop a comment below. You'll need to register with the hub first, its free and easy to do.
  19. News Article
    NHS England said it had opened a tender worth £16 million to support provider organisations as they seek to improve their digital maturity and get electronic patient records in place by the end of March 2026. NHSE said its frontline digitisation programme is working with NHS secondary care trusts providing acute specialist, community, mental health and ambulance services to help them reach a minimum level of digital capability as defined by the Digital Capabilities Framework. To fulfil this ambition, NHSE is seeking a partner to create an experienced, multi-skilled, rapid response intervention service, also known as a Tiger Teams service, capable of supporting EPR delivery across England. This service will be an expansion to an existing comprehensive support offer available to providers, designed to support the national demand for resource, expertise, and information necessary to successfully rollout EPRs. NHSE said: “Often during EPR delivery, there is a requirement for either a planned, or unplanned, specific, time-bound skill set, capable of providing a set of deliverables, problem rectification or other specialist intervention for an element of the EPR Programme. “Trusts are finding it increasingly challenging to obtain good quality, skilled short-term resources, both from the recruitment and contingent labour market.” Read full story Source: Digital Health, 22 January 2024
  20. News Article
    A "significant deterioration" in leadership at an NHS trust probably had a "knock-on effect" on its standard of services, a watchdog has found. Inspectors found staff felt encouraged to "turn a blind eye" to bullying in hospitals run by the Newcastle Hospitals NHS Foundation Trust. The Care Quality Commission (CQC) downgraded the trust's overall rating to "requires improvement". The trust said it "fully accepts" the report and that recommendations were being worked on "as a matter of urgency". Ann Ford, CQC's director of operations in the north, said: "We found a significant deterioration in how well the trust was being led. "Our experience tells us that when a trust isn't well led, this has a knock-on effect on the standard of services being provided to people. "Some staff told us that bullying was a normal occurrence, and they were encouraged to 'turn a blind eye' and not report this behaviour. "This is completely unacceptable." Read full story Source: BBC News, 25 January 2024
  21. Content Article
    Great Ormond Street Hospital NHS Foundation Trust is one of the world’s leading children’s hospitals, receiving 242,694 outpatient visits and 42,112 inpatient visits every year (figures from 2021/22). This paper seeks to provide an overview of the safety systems and processes Great Ormond Street Hospital has in place to keep patients, staff, and healthcare environments safe.
  22. News Article
    The Health and Social Care Committee has launched a new inquiry to examine leadership, performance and patient safety in the NHS. Inquiry: NHS leadership, performance and patient safety MPs will consider the work of the Messenger review (2022) which examined the state of leadership and management in the NHS and social care, and the Kark review (2019) which assessed how effectively the fit and proper persons test prevents unsuitable staff from being redeployed or re-employed in health and social care settings. The Committee’s inquiry will also consider how effectively leadership supports whistleblowers and what is learnt from patient safety issues. An ongoing evaluation by the Committee’s Expert Panel on progress by government in meeting recommendations on patient safety will provide further information to the inquiry. Health and Social Care Committee Chair Steve Brine MP said: “The role of leadership within the NHS is crucial whether that be a driver of productivity that delivers efficient services for patients and in particular when it comes to patient safety. Five years ago, Tom Kark QC led a review to ensure that directors in the NHS responsible for quality and safety of care are ‘fit and proper’ to be in their roles. We’ll be questioning what impact that has made. We’ll also look at recommendations from the Messenger review to strengthen leadership and management and we will ask whether NHS leadership structures provide enough support to whistleblowers. Our Expert Panel has already begun its work to evaluate government progress on accepted recommendations to improve patient safety so this will build on that. We owe it to those who rely on the NHS – and the tax-payers who pay for it – to know whether the service is well led and those who have been failed on patient safety need to find out whether real change has resulted from promises made.” Terms of Reference The Committee invites written submissions addressing any, or all, of the following points, but please note that the Committee does not investigate individual cases and will not be pursuing matters on behalf of individuals. Evidence should be submitted by Friday 8 March. Written evidence can be submitted here of no more than 3,000 words.  How effectively does NHS leadership encourage a culture in which staff feel confident raising patient safety concerns, and what more could be done to support this? What has been the impact of the 2019 Kark Review on leadership in the NHS as it relates to patient safety? What progress has been made to date on recommendations from the 2022 Messenger Review? How effectively have leadership recommendations from previous reviews of patient safety crises been implemented? How could better regulation of health service managers and application of agreed professional standards support improvements in patient safety? How effectively do NHS leadership structures provide a supportive and fair approach to whistleblowers, and how could this be improved? How could investigations into whistleblowing complaints be improved? How effectively does the NHS complaints system prevent patient safety incidents from escalating and what would be the impact of proposed measures to improve patient safety, such as Martha’s Rule? What can the NHS learn from the leadership culture in other safety-critical sectors e.g. aviation, nuclear? Read full story Source: UK Parliament, 25 January 2024
  23. Content Article
    This study from Jalilian et al., published in the BMJ, evaluated the length of stay difference and its economic implications between hospital patients and virtual ward patients. It found that the use of a 40-bed virtual ward was clinically effective in terms of survival for patients not needing readmission and allowed for the freeing of three hospital beds per day. However, the cost for each day freed from hospital stay was three-quarters larger than the one for a single-day hospital bed. This raises concerns about the deployment of large-scale virtual wards without the existence of policies and plans for their cost-effective management.
  24. News Article
    Researchers have found the costs of treating patients in a 40-bed virtual ward were double that of traditional inpatient care. The study’s authors said the findings should raise concerns over a flagship NHS England policy, which has driven the establishment of 10,000 virtual ward beds. Virtual wards, sometimes described as “hospital at home”, are cited as a safe way to reduce pressure on hospitals, by reducing length of stay and enabling quicker recovery. The study at Wrightington Wigan and Leigh Teaching Hospitals, in Greater Manchester, found a clear reduction in length of stay but also found higher rates of readmission. The authors said this led to additional costs, with the cost of a bed day in the virtual ward estimated at £1,077, compared to £536 in a general inpatient hospital bed. “This raises concerns [over] the deployment of large-scale virtual wards without the existence of policies and plans for their cost-effective management. This evidence should be taken into consideration by [the] NHS in planning the next large deployment of virtual wards within the UK… “Virtual wards must be cost effective if they are to replace traditional inpatient care, the costs must be comparable or lower than the costs of hospital stay to be economically sustainable in the medium to long terms.” To break even, the paper said the virtual ward would need to double its throughput, but warned this would risk lowering the standard of care. Read full story (paywalled) Source: HSJ, 25 January 2024
  25. News Article
    A group of doctors with Long Covid are preparing to launch a class action for compensation after contracting SARS-CoV-2 at work. The campaign and advocacy group Long Covid Doctors for Action (LCD4A) has engaged the law firm Bond Turner to bring claims for any physical injuries and financial losses sustained by frontline workers who were not properly protected at work. On 25 January Bond Turner, which specialises in negligence cases, complex litigation, and group actions, launched a call to action inviting doctors and other healthcare workers in England and Wales to make contact if they believe that they contracted covid-19 as a result of occupational exposure.1 Sara Stanger, the firm’s director and head of clinical negligence and serious injury claims, said that the ultimate aim was to achieve “legal accountability and justice for those injured.” She told The BMJ, “I’ve spoken to hundreds of doctors with long covid, and many of them have had their lives derailed. Some have lost their jobs and their homes; they are in financial ruin. Their illnesses have had far reaching consequences in all areas of their lives.” Read full story Source: BMJ, 25 January 2024 Nurses, midwives, and any other healthcare workers who are suffering with Long Covid and which they believe they contracted through their work and who wish to join the action should visit the Bond Turner website here: https://www.bondturner.com/services/covid-group-claim/. Although this action has been initiated by doctors in the first instance, it is not limited to doctors. Further reading on the hub: Questions around Government governance My experience of suspected 'Long COVID' How will NHS staff with Long Covid be supported?
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