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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Factors such as racism and social inequality may have contributed to increased risks of black, Asian and minority communities catching and dying from COVID-19, a leaked report says. Historic racism may mean that people are less likely to seek care or to demand better personal protective equipment, says the Public Health England (PHE) draft, seen by the BBC. Other possible factors include risks linked to occupation and inequalities in conditions such as diabetes may increase disease severity. The report, the second by PHE on the subject, pointed to racism and discrimination as a root cause affecting health and the risk of both exposure to the virus and becoming seriously ill. It said stakeholders expressed "deep dismay, anger, loss and fear in their communities" as data emerged suggesting COVID-19 was "exacerbating existing inequalities". And it found "historic racism and poorer experiences of healthcare or at work" meant individuals in BAME groups were less likely to seek care when needed or to speak up when they had concerns about personal protective equipment or risk. The report concluded: "The unequal impact of COVID-19 on BAME communities may be explained by a number of factors ranging from social and economic inequalities, racism, discrimination and stigma, occupational risk, inequalities in the prevalence of conditions that increase the severity of disease including obesity, diabetes, hypertension and asthma." Read full story Source: BBC News, 13 June 2020
  2. Content Article
    Clinical negligence claims are often built upon a lack of adequate documentation of what was said and allegations that patients have not been properly counselled about risks and alternatives. Elizabeth Thomas explores in this HSJ article what this means for the increasingly significant role of telemedicine and the steps which can go a long way in reducing the burden on patients and the public purse
  3. Content Article
    Stress urinary incontinence is when you leak urine accidentally, especially during exercise or when you cough, laugh or sneeze. The National Institute for Health and Care Excellence (NICE) has produced a diagram that shows what treatments NICE recommends as options for managing stress urinary incontinence. If you have tried to manage your condition without surgery, but this hasn’t worked, you might like to think about surgery. This decision aid can help you and your surgeon decide together which type of surgery is best for you. You might also decide that you don’t want to have any surgery. It is important to make the choice that you feel is right for you. This will depend on your individual circumstances and how you feel about each type of surgery. Every woman is different, so this decision aid is only a guide. Information about how this decision aid was produced and the evidence on which it is based is available on the NICE website.
  4. Content Article
    Lewis Thomas and Kieran McHugh, trainees on the NHS graduate management scheme working at Imperial College Healthcare Trust and North Central London CCG respectively, share with HSJ their reflections on leadership having worked during the COVID-19 pandemic
  5. News Article
    A report containing measures to protect ethnic minority groups from coronavirus has been drawn up for government, BBC News has learned. Public Health England (PHE) published a review last week confirming coronavirus kills people from ethnic minorities at disproportionately high rates. But a senior academic told BBC News a second report, containing safeguarding proposals to tackle this, also existed. And PHE now says this report will be published next week. Labour described the decision not to immediately publish the second report as "scandalous and a tragedy". Read full story Source: BBC News, 11 June 2020
  6. Event
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    The Institute of Healthcare Management (IHM) are partnering with The Academy of Fabulous NHS Stuff and the Royal Wolverhampton Hospital NHS Trust to present their ‘No Going Back’ online conference. What have we learnt, what have we done differently, what technical innovations have we found indispensable during this coronavirus crisis? Together, with members, we will bring you case studies and discuss the importance of ‘No Going Back’. Join what will be a thoroughly interesting and interactive discussion, on a highly anticipated and talked about topic within health and care organisations. Registration
  7. Content Article
    Professor Donna Kinnair, the head of the Royal College of Nursing, in her blog to the Guardian talks about why the health service is failing people of colour – both those using it and its workforce. "As a black leader, you are always aware that if you are not a good role model, someone coming up behind you may not be afforded the same opportunity you’ve been given. There are, sadly, too few of us. We only have 10 black, Asian and minority ethnic (BAME) chief nurses across the whole of the NHS in England. The leadership of the NHS is not reflective of the workforce, or the communities we serve."
  8. Community Post
    In April, Lord Wills posed the following parliamentary question "What steps are the government taking to remind NHS trusts of their responsibilities to whistleblowers". The impact of COVID-19 has seen an increase in whistleblowing amongst key-workers in hospital and care settings. There is a duty to protect whistleblowers who speak out and challenge their employers. Encouraging the right for staff to speak out without fear of repercussion ensures that proactive measures are taken to protect the lives of NHS and care workers. Read the parliamentary response here: https://www.appgwhistleblowing.co.uk/post/parliamentary-questions-1?postId=5ee2bf71e6ab0a0017d86925
  9. Content Article
    While healthcare workers fight on behalf of us all against COVID-19, they can still risk their jobs for blowing the whistle on dangerous practices and wrongdoing. In fact whistleblowing and the global crisis caused by COVID-19 are closely intertwined. We know from staff at whistleblower helplines that healthcare is the sector from which they get most calls. But it can be extremely difficult for healthcare staff to effectively report problems.  In this blog, Professor Kate Kenny and Professor Marianna Fotaki discuss how drawing attention to wrongdoing and risks has long been a problem, forcing staff to become whistleblowers, often at high personal cost to themselves. However, healthcare whistleblowers need help to speak out, now more than ever now, when timely disclosures can help prevent major disasters. Building transparent and fit-for-purpose channels for disclosing and preventing wrongdoing is key for achieving this. Senior healthcare managers, politicians, and unions must also fight hard to be the voices of frontline healthcare staff who struggle to draw attention to serious issues they encounter at work.
  10. Content Article
    Patient Safety Learning interviews a critical care outreach nurse who has been shielding during the pandemic and hears about the effect it has had on her and the support she has received.
  11. News Article
    Young people with learning disabilities are being driven to self-harm after being prevented from seeing their families during the coronavirus lockdown in breach of their human rights, a new report finds. The Joint Committee on Human Rights warned that the situation for children and young people in mental health hospitals had reached the point of “severe crisis” during the pandemic due to unlawful blanket bans on visits, the suspension of routine inspections and the increased use of restraint and solitary confinement. The report concluded that while young inpatients' human rights were already being breached before the pandemic, the coronavirus lockdown has put them at greater risk – and called on the NHS to instruct mental health hospitals to resume visits. It highlighted cases in which young people had been driven to self-harm, including Eddie, a young man with a learning disability whose mother, Adele Green, had not been able to visit him since 14 March. “When the lockdown came, it was quite quick in the sense that the hospital placed a blanket ban on anybody going in and anybody going out,” said Ms Green. “Within a week, with the fear and anxiety, he tried to take his own life, which really blew us away. We were mortified.” The Committee is urging NHS England to write to all hospitals, including private ones, stating they must allow visits unless there is a specific reason relating to an individual case why it would not be safe, and said the Care Quality Commission (CQC) should be responsible for ensuring national guidance is followed. Read full story Source: The Independent, 12 June 2020
  12. News Article
    Huge numbers of people with suspected cancer were not referred to hospital for urgent checks or did not have a test during the first month of the lockdown, prompting fears that late diagnosis of the disease will reduce some patients’ chances of survival. Unprecedented numbers of cancer patients missed out on vital treatments, diagnostic tests and outpatient appointments as the pandemic unfolded, NHS England data shows. Macmillan Cancer Support estimates that 210,000 people should have entered the system this month. That means roughly 130,000 people who would ordinarily be referred to a consultant have not been. About 7% of these patients would usually require cancer treatment, meaning approximately 9,000 people might not have had their cancer diagnosed in April. The organisation said that around 2,500 people who should have been referred for their first treatment after a cancer diagnosis will not have received that treatment. Read full story Source: The Guardian, 11 June 2020
  13. News Article
    Relatives of 450 people who have died in the coronavirus pandemic are demanding an immediate public inquiry. The families want an urgent review of "life and death" steps needed to minimise the continuing effects of the virus and a guarantee that documents relating to the crisis will be kept. A full inquiry would take place later, says lawyer, Elkan Abrahamson, who is representing the families. The government has said its current focus is on dealing with the pandemic. But the COVID-19 Bereaved Families for Justice UK group say immediate lessons need to be learned to prevent more deaths, and that waiting for ministers to launch an inquiry will cost lives. The call for an inquiry comes as a report from the National Audit Office - assessing the readiness of the NHS and social care in England for the pandemic - has shown it is not known how many of the 25,000 people discharged from hospitals into care homes at the peak of the outbreak were infected with coronavirus. Health and Social Care Select Committee chairman Jeremy Hunt said it seemed "extraordinary that no one appeared to consider" the risk. The Department of Health says it took the "right decisions at the right time". Read full story Source: BBC News, 12 June 2020
  14. News Article
    Thousands of people lost their lives “prematurely” because care homes in England lacked the protective equipment and financial resources to cope with the coronavirus outbreak, according to council care bosses. In a highly critical report, social care directors say decisions to rapidly discharge many vulnerable patients from NHS hospitals to care homes without first testing them for COVID-19 had “tragic consequences” for residents and staff. In many places, vulnerable people were discharged into care facilities where there was a shortage of personal protective equipment (PPE) or where it was impossible to isolate them safely, sometimes when they could have returned home, the report says. “Ultimately, thousands have lost their lives prematurely in social care and were not sufficiently considered as part of wider health and community systems. And normality has not yet returned,” James Bullion, the president of the Association of Directors of Adult Social Services (Adass), said in a foreword to the report. Read full story Source: The Guardian, 11 June 2020
  15. Content Article
    In this Editorial in Occupational Medicine, Raymond Agius asks why when millions of people are in ‘lockdown’ in their own homes to avoid the contagion of COVID-19, many workers lack a comparable degree of protection. The planning and logistics of contending with this pandemic may be analogous to those of war, but we are not in a conflict: workers’ lives need not and must not be lost. "On the face of it, the conclusion that during this pandemic thousands of workers may have been seriously jeopardized and denied the safeguards that are theirs by right is difficult to refute."
  16. Event
    Addressing Social Disparities webinar. This 1 hour webinar will be featuring Dr. Marcus Robinson with Collaboraction, Patricia Merryweather-Arges with Project Patient Care, Dr. Daria B. Terrell with St. Bernard Hospital and Health Care Center and Dr. Ron Wyatt with MCIC Vermont. Zoom is requiring a new update before you can join any meeting. Please make sure to update here before hand to avoid missing any of the webinar. Zoom registration
  17. Content Article
    "Many things will change as a result of the COVID-19 pandemic. One of them has to be the safety culture in medicine. Those in positions of authority must stop paying lip service to it and instead treat frontline workers as equal partners in the drive to improve safety, not as expendable infantry who can be bullied over the top with impunity or scapegoated ‘pour encourager les autres'", says Dr David Berger, a remote hospital doctor in Northern Australia. In this blog, David discusses how a robust, modern safety culture involves the closest possible partnership between management and frontline workers, where concerns can be shared freely, cooperation is total and where all interested parties must agree that the best possible system is in place.
  18. News Article
    Inspectors have placed a women’s mental health service into special measures after patients were said to have been subjected to “inappropriate” and “derogatory” treatment by staff. St Andrew’s Healthcare, which runs the women’s inpatient facility in Northampton, has received a series of damning reports among its services over the past two years. The inspectors noted during visits between February and March that staff reportedly used language to describe patients on a medium secure ward such as “self-harmers”, “attention seeking”, and “kicking off”. Patients said staff used “inappropriate restraint techniques that caused pain” with reports they “bent the patient’s wrist and arm behind their back.” They also said staff spoke to them in a “derogatory manner, for example telling them to sort themselves out when engaging in self harm behaviour.” Inspectors rated the service “inadequate” overall, noting concerns elsewhere including “forensic failure incidents due to staff shortages”, that staff were not reporting all safeguarding concerns and that “managers did not ensure safe and clean environments in the long stay rehabilitation service and learning disability service.” Read full story Source: HSJ, 10 June 2020
  19. News Article
    Babylon Health is investigating whether NHS patients were among those affected by a 'software error' that allowed people registered with its private GP service to view recordings of other people's consultations earlier this month. Babylon Health has confirmed that a small number of patients were able to view recordings of other patients' consultations earlier this week. The issue came to light after a patient in Leeds who had access to the Babylon app through a private health insurance plan with Bupa reported that he had been able to view around 50 consultations that were not his own. The patient told the BBC he was 'shocked' to discover the data breach. "You don't expect to see anything like that when you're using a trusted app," he said. "It's shocking to see such a monumental error has been made." Babylon told GPonline that the app used by private and NHS patients is the same, but it had yet to confirm whether the roughly 80,000 patients registered with the company's digital first NHS service GP at Hand were among those affected. The problem is understood to have cropped up when a new feature was introduced for patients who switched from audio to video mid-way through a consultation. Read full story Source: GPOnline, 10 June 2020
  20. News Article
    An independent investigation into working conditions at a unit of the NHS’s blood and organ transplant service has concluded that it is “systemically racist” and “psychologically unsafe.” The internal investigation was commissioned in response to numerous complaints from ethnic minority staff working in a unit of NHS Blood and Transplant (NHSBT) in Colindale, north London. The report, carried out by the workplace relations company Globis Mediation Group, concluded that the environment was “toxic” and “dysfunctional.” The report found evidence that ethnic minority employees had faced discrimination when applying for jobs and that white candidates had been selected for posts ahead of black applicants who were better qualified. “Recruitment is haphazard, based on race and class and whether a person’s ‘face fits,’” it said. “Being ignored, being viewed as ineligible for promotion and enduring low levels of empathy all seem to be normal,” the report noted. “These behaviours have created an environment which is now psychologically unsafe and systemically racist.” Chaand Nagpaul, BMA council chair, commented, “This report highlights all too painfully the racial prejudices and discrimination we are seeing across healthcare. We must renew efforts to challenge these behaviours and bring an end to the enduring injustices faced by black people and BAME healthcare workers here in the UK.” Read story Source: BMJ, 10 June 2020
  21. News Article
    More than 60% of new covid cases diagnosed at two hospitals in the Midlands in recent days were caught at least two weeks after the patient was admitted — suggesting there may be particular problems with the virus spreading on their wards. Northamptonshire is also still grappling with larger numbers of covid cases in hospital, in contrast to most of England. Its NHS organisations have said they do not know the cause of its ongoing problems. But the large share of cases diagnosed among patients who have been in hospital for at least 15 days – classed by NHS England as definitely “healthcare associated” – indicate that problems controlling the spread within the hospitals may be playing a significant part, rather than the outbreaks in the community. There has been major national concern about in-hospital spread of the virus in recent weeks, with the government introducing new mandatory controls on Friday. Read full story Source: HSJ, 11 June 2020
  22. News Article
    Those recovering from Covid-19 are to be given devices which can help spot dips in their blood oxygen-levels while they recover at home. The NHS is trialling the use of oximeters, combined with an app, which will make it easier to spot whether people need to be re-admitted to hospital. The new oximeter service is being tested with more than 150 patients in sites on Watford, Hertfordshire and north London. Clinicians in ‘virtual wards’ are able to track patients’ vital signs – including temperature, heart rate and blood oxygen saturation – in near real-time, receiving alerts if they suggest a patient is deteriorating so that further assessments and care can be arranged. Health and Social Care Secretary, Matt Hancock, said: “While we restore face to face NHS services too, new innovations will ensure patients can benefit from the comfort of home, with the reassurance that they can be fast tracked to support from the NHS should they need. NHS at Home will help keep people safe and out of hospital while providing the best possible care.” Read full story Source: Digital Health, 5 June 2020
  23. News Article
    A poll of members by the Medical Protection Society (MPS) found that 43% of doctors fear investigation if patients come to harm because of delays to referrals and reduced NHS services during the pandemic. Treatment has been delayed for millions of patients while the NHS has focused on managing the pandemic - with GPs in many areas still unable to refer as normal and even urgent referrals delayed while the UK has been in lockdown. The NHS Confederation has warned that 10 million people could be on NHS waiting lists by Christmas. Reduced NHS services during the pandemic have left even patients who need urgent treatment or scans for cancer waiting longer. GPonline reported in April that patients had been waiting more than a month for urgent cancer checks - and Cancer Research UK warned in May that 2.4 million patients were waiting longer for scans or treatment because of disruption to services during the pandemic. Read full story Source: GPonline, 11 June 2020
  24. Content Article
    Lewis Hornby had a problem: his grandmother, who suffers from dementia, wasn’t drinking enough water, causing her to get severely dehydrated. In this TEDx Talk, Lewis shares his sweet, and potentially life-saving, solution. Lewis is a recent graduate of the Innovation Design Engineering program at the Royal College of Art and Imperial College London. His Jelly Drops design has received multiple awards for design engineering and social impact.
  25. News Article
    The aftercare of COVID-19 patients will have significant financial implications for ‘understaffed’ community services, NHS England has been warned. This month the national commissioner released guidance for the care of patients once they have recovered from an immediate covid infection and been discharged from hospital. It said community health services will need to provide “ongoing health support that rehabilitates [covid patients] both physically and mentally”. The document said this would result in increased demand for home oxygen services, pulmonary rehabilitation, diagnostics and for many therapies such as speech and language, occupational, physio, dieticians and mental health support. One GP heavily involved in community rehab told HSJ: “There is a lot detailed information about what people might experience in recovery, but it doesn’t say what should actually happen. “We have seen people discharged from hospital that don’t know anything about their follow-up and the community [health sector] hasn’t got any instructions of what they should be doing or what services have even reopened. This guidance needs to go a step further and rapidly say what is expected so local commissioners can put that in place.” Read full story Source: HSJ, 10 June 2020
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