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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
    Clinical Audit for Improvement 2024 is now in its 24th year and brings together clinicians, senior/middle managers and leading local and national clinical audit and improvement experts. Over the last two decades this event has become the ‘must-attend’ annual conference for clinical audit and QI professionals. Historically this one-day virtual conference has featured national updates with leaders providing information on relevant current and future policy. However, in 2024 the focus will change slightly with more emphasis on practical skills and techniques needed by those involved in delivering clinical audit projects at a local and/or national level. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/clinical-audit-improvement-summit or email frida@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for the discount code. Follow on Twitter @HCUK_Clare #ClinicalAudit2024
  2. Event
    This conference focuses on recognising and responding to the deteriorating patient and ensuring best practice in the use of NEWS2. The conference will include national developments, including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, the role of human factors in responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and Covid-19, involving patients and families in recognising deterioration, using clinical judgement, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. The Recording of NEWS2 score, escalation time and response time for unplanned critical care admissions is now an NHS CQUIN goal. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/deteriorating-patient-summit or email aman@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for the discount code. Follow on Twitter @HCUK_Clare #DeterioratingPatient
  3. Content Article
    This study published in JAMA Internal Medicine looked at how often diagnostic errors happened in adult patients who are transferred to the intensive care unit (ICU) or die in the hospital, what causes the errors, and what are the associated harms. In this cohort study of 2428 patient records, a missed or delayed diagnosis took place in 23%, with 17% of these errors causing temporary or permanent harm to patients. The underlying diagnostic process problems with greatest effect sizes associated with diagnostic errors, and which might be an initial focus for safety improvement efforts, were faults in testing and clinical assessment.
  4. Content Article
    The Covid-19 pandemic led to unprecedented healthcare disruption across the UK. In England, the number of patient referrals waiting to be treated in hospital was more than 7·2 million at the end of October, 2022. In response, the UK Government set up an elective recovery taskforce (ERT) in December, 2022, to help NHS England tackle this backlog. Ahmar Shah and colleagues estimated the extent of healthcare disruption during the Covid-19 pandemic to aid decision making regarding the necessary capacity increases that are required to address the ensuing backlog. The study, published in The Lancet, found NHS waiting list for elective treatment increased between 1 Jan 2012, and the start of the Covid-19 pandemic, suggesting a gradual service decline. The waiting list then substantially increased during the pandemic, but this substantial increase is likely to represent a substantial underestimation of the backlog because of the anticipated large numbers of people who have still not come forward for care. Even if the ambitious target of 30% increase in capacity is achieved during the next 3 years, several years (beyond the end of 2025) will be needed for the backlog to clear. This study emphasises the need to improve health-care system resilience to ensure that the effects of any future emergencies on the provision of routine care are minimised.
  5. News Article
    The NHS must treat at least 10% more non-emergency hospital cases a month if it wants to reduce the hefty backlog caused by the pandemic, according to new analysis. From February 2020 to October 2022, the waiting list for non-urgent care in England grew by 2.6m cases – a projected 1.8m more than if the pandemic had not hit. NHS England’s recovery plan aims to increase capacity by 30% by 2025 compared with pre-pandemic levels, but figures published on Thursday showed that the waiting list in England stood at 7.6m, down just 1.3% from the previous month. Researchers at the Universities of Edinburgh and Strathclyde examined the number of referrals awaiting treatment between January 2012 and October 2022. They calculated that an estimated 10.2m fewer referrals were made to elective care from the beginning of the pandemic to 31 October 2022. They then modelled how many of these missing patients might return for care to estimate the potential impact on waiting lists. NHS trusts would have to treat more than 10% to reverse the increasing trend in waiting lists, the authors conclude. “Even if the ambitious target of 30% increase in capacity is achieved during the next three years, several years (beyond the end of 2025) will be needed for the backlog to clear.” The research comes as NHS England monthly data published on Thursday revealed the health service is going backwards on some key targets. Read full story Source: The Guardian, 11 January 2024
  6. News Article
    Thousands of patients are being readmitted to NHS mental health units in England every year soon after being discharged, raising concerns about poor care, bed shortages and increased risk of suicide. Experts say being discharged prematurely can be upsetting, set back the patient’s chances of making a full recovery and be “disastrous” for their health. Figures from NHS mental health trusts in England show that last year almost 5,000 people – children and adults – were readmitted to a mental health facility within a month of leaving. The Labour MP Dr Rosena Allin-Khan said the “alarming” data, which she obtained under freedom of information laws, showed too many patients were not receiving enough help to recover. Allin-Khan said: “With record waiting lists and mental health beds in short supply, it is alarming that many patients are being discharged only to be readmitted within days. Every patient expects to receive full and appropriate mental health support, so it is concerning that in many cases patients are being discharged prematurely. “Being discharged too soon can have a disastrous impact, stunting progress towards a full recovery, ultimately causing further damage to a patient’s mental health.” Read full story Source: The Guardian, 12 January 2024
  7. Content Article
    A series of LinkedIn articles on systems thinking from Phil Evans, Independent HealthTech Consultant.
  8. Content Article
    Antonio Gonzalez speaks to Susan Standford for the Yale Anesthesiology podcast on intraoperative pain. Susanna is a patient who experienced intraoperative pain, and knowing she was not alone, she has actively raised awareness of this issue. In her own words, “Being able to feel major abdominal surgery is every bit as horrific as it sounds.” They discuss neuraxial anaesthesia for CS, guidance on testing and managing blocks, women being labelled ‘anxious’, outcome measures and targets.
  9. Content Article
    Jessie Cunnett, new CEO at the Point of Care Foundation, shares her journey of commitment to humanise healthcare through her personal and professional stories. She reflects on the importance of creating space for everyone to feel seen and heard in health and care settings.
  10. Event
    The Patient Advocacy Leadership Collective (PALC) is an innovative hub that provides connectivity, community resources, and tools focused on sustainable capacity building for patient advocates globally. Advocacy skills are necessary for patient organisations as these allow the patients to actively participate in their healthcare, improve communication with healthcare providers, access information and resources, and contribute to positive changes in the healthcare system. The PALC is an excellent platform that is focused on supporting the growth, development, and leadership of patient advocacy organizations and offers a NextGen Leadership, Mentorship, and Global Health Fellows program. The PALC has been developed by leading global patient advocacy leaders with support from Pfizer. The purpose of this webinar is to spread awareness and build capacities by taking all concerned through this very important tool for Patient Advocacy. Register
  11. Event
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    Together with the Türkiye Health Care Quality and Accreditation Institute (TUSKA) and the Ministry of Health, Türkiye, ISQua is delighted to host their 40th International Conference in Istanbul. The theme for the 2024 conference is 'Health for People and Planet: Building Bridges to a Sustainable Future'. It will address the continued challenges of making person-centred care part of the healthcare system, as well as addressing some of the hot topics that matter most in a rapidly changing world. Issues such as environmental challenges, reducing the healthcare sector's carbon footprint, and ensuring the long-term resilience of healthcare will be addressed at the conference. It will also examine the potentials and pitfalls of AI and Digital Transformation in healthcare, and how it can revolutionise healthcare and enable better patient engagement. Further information
  12. News Article
    Long Covid costs the UK at least an extra £23m in GP and other primary care consultations each year, according to estimates in a new study. The University of Birmingham said extra appointments cost between £23m and £60m a year. The study examined more than 950,000 electronic healthcare records since the start of the global pandemic. People with Long Covid report symptoms including persistent coughs and brain fog. The condition is defined as having symptoms three months after the initial infection, which last for two months or more. Factors found to increase primary care costs included being older, female, white, obese or someone with long-term health conditions. Co-lead author Dr Shamil Haroon, from the university, said: "We might expect that patients who are older or who have long-term health conditions will need additional primary care support, but we have also seen additional costs associated with being white and female." Read full story Source: BBC, 11 January 2024
  13. Content Article
    The economic impact of managing Long Covid in primary care is unknown. In a study published in BMC Primary Care, Tufts et al. estimated the costs of primary care consultations associated with Long Covid and explored the relationship between risk factors and costs. The study found that costs of primary care consultations associated with Long Covid in non-hospitalised adults are substantial. Costs are significantly higher among those diagnosed with Long Covid, those with Long Covid symptoms, older adults, females, and those with obesity and comorbidities.
  14. News Article
    The number of women dying during pregnancy or soon after childbirth has reached its highest level in almost 20 years, according to new data. Experts have described the figures as “very worrying”. Between 2020 and 2022, 293 women in the UK died during pregnancy or within 42 days of the end of their pregnancy. With 21 deaths classified as coincidental, 272 in 2,028,543 pregnancies resulted in a maternal death rate of 13.41 per 100,000. This is a steep rise from the 8.79 deaths per 100,000 pregnancies in 2017 to 2019, the most recent three-year period with complete data. The death rate has increased to levels not seen since 2003 to 2005. The data comes from MBRRACE-UK, which conducts surveillance and investigates the causes of maternal deaths, stillbirths and infant deaths as part of the national Maternal, Newborn and Infant Clinical Outcome Review Programme (MNI-CORP). Urgent action is needed to bolster the quality of maternal healthcare, ensure it is accessible to all, and repair the damage inflicted by the pandemic on women’s healthcare services more generally. Clea Harmer, the chief executive of bereavement charity Sands, said improving maternity safety also needs to be at the top of the UK’s agenda. The government said it was committed to ensuring all women received safe and compassionate care from maternity services, regardless of their ethnicity, location or economic status. Anneliese Dodds, the shadow women and equalities secretary, said Labour would seek to reverse the “deeply concerning” maternal mortality figures by training thousands more midwives and health visitors and incentivising continuity of care for women during pregnancy. Read full story Source: The Guardian, 11 January 2024
  15. Content Article
    Learning vicariously from the experiences of others at work, such as those working on different teams or projects, has long been recognised as a driver of collective performance in organisations. Yet as work becomes more ambiguous and less observable in knowledge-intensive organisations, previously identified vicarious learning strategies, including direct observation and formal knowledge transfer, become less feasible. Drawing on ethnographic observations and interviews with flight nurse crews in an air medical transport program, Chris Myers inductively build a model of how storytelling can serve as a valuable tool for vicarious learning. He explores a multistage process of triggering, telling, and transforming stories as a means by which flight nurses convert the raw experience of other crews’ patient transports into prospective knowledge and expanded repertoires of responses for potential future challenges. Further, he highlights how this storytelling process is situated within the transport programme’s broader structures and practices, which serve to enable flight nurses’ storytelling and to scale the lessons of their stories throughout the entire programme. He discusses the implications of these insights for the study of storytelling as a learning tool in organizations, as well as for revamping the field’s understanding of vicarious learning in knowledge-intensive work settings.
  16. News Article
    A British mother-of-three has died just days after undergoing a Brazilian bum-lift operation in Turkey. Demi Agoglia, 26, of Salford, Greater Manchester, died from a heart attack caused by the operation just hours before she was due to return to Manchester from Istanbul where she had the operation, her family said. Ms Agoglia, who had a seven-month-old baby boy, went back to the clinic in Istanbul for a check-up but had a heart attack in a taxi on the way to the hospital as her partner, Bradley Jones, gave her CPR in a desperate bid to save her life. Her brother Carl, 37, said Ms Agoglia’s family and partner had tried to convince her not to go through with the bum-lift as they were concerned for her safety. Last year, a British surgeon warned of the dangers faced by Brits who fly to countries like Turkey for cheaper cosmetic surgery. “Many people fail to do their research and focus too much on money, rather than the quality or safety of the clinic,” Dr Ahmed Alsayed, who is lead surgeon and medical director at plastic surgery specialists Signature Clinic told HullLive. “Clinics in the UK have to adhere to the strictest levels of expertise, safety and cleanliness. You just can’t be sure you’ll get that from a cheaper option abroad,” Dr Alsayed said. Read full story Source: The Independent, 10 January 2023
  17. News Article
    Women who experience depression during pregnancy or in the year after giving birth are at a higher risk of suicide and attempting suicide, researchers have warned. The British Medical Journal study warned that women who develop perinatal depression are twice as likely to die compared to those who don’t experience depression. Suicide was the leading cause of death for women in the UK in 2022 between six weeks and one year after birth, while deaths from psychiatric causes accounted for almost 40 per cent of maternal deaths overall, according to a Perinatal Mortality Surveillance report. Last year an analysis by Labour revealed 30,000 women who were pregnant were on waiting lists for specialist mental health support. The number of women waiting rose by 40 per cent between August 2022 and March 2023. The most recent NHS data shows in September 2023, 61,000 women accessed perinatal mental health services. For 2023-24, the health service must hit a target to have 66,000 women accessing care. In August 2023, the Royal College of Midwives published a research warning half of anxiety and depression cases among new and expectant mothers were being missed amid NHS staff shortages in maternity care. Read full story Source: The Independent, 11 January 2024
  18. Content Article
    The Parkinson’s Excellence Network has launched three new practical guides to support UK health professionals to deliver time critical Parkinson’s medication on time in hospital.
  19. News Article
    The UK has some of the worst cancer survival rates in the developed world, according to new research. Analysis of international data by the Less Survivable Cancers Taskforce found that five-year survival rates for lung, liver, brain, oesophageal, pancreatic and stomach cancers in the UK are worse than in most comparable countries. On average, just 16% of UK patients live for five years with these cancers. Out of 33 countries of comparable wealth and income levels, the UK ranks as low as 28th for five-year survival of both stomach and lung cancer, 26th for pancreatic cancer, 25th for brain cancer and 21st and 16th for liver and oesophageal cancers respectively. The six cancers account for nearly half of all common cancer deaths in the UK and more than 90,000 people are diagnosed with one of them in Britain every year. The taskforce calculated that if people with these cancers in the UK had the same prognosis as patients living in countries with the highest five-year survival rates – Korea, Belgium, the US, Australia and China – then more than 8,000 lives could be saved a year. Anna Jewell, the chair of the Less Survivable Cancers Taskforce, said: “People diagnosed with a less survivable cancer are already fighting against the odds for survival. If we could bring the survivability of these cancers on level with the best-performing countries in the world then we could give valuable years to thousands of patients. “If we’re going to see positive and meaningful change then all of the UK governments must commit to proactively investing in research and putting processes in place so we can speed up diagnosis and improve treatment options.” Read full story Source: The Guardian, 11 January 2023
  20. Content Article
    MBRRACE have released their latest UK maternal mortality figures. The maternal death rate in 2020-22 was 13.41 per 100,000 maternities. This is significantly 53% higher than the rate of 8.79 deaths per 100,000 maternities in the previous three year period (2017-19).
  21. Content Article
    This study published in BMJ Quality & Safety identified factors acting as barriers or enablers to the process of healthcare consent for people with intellectual disability and to understand how to make this process equitable and accessible. The study found that multiple reasons contribute to poor consent practices for people with intellectual disability in current health systems. Recommendations include addressing health professionals’ attitudes and lack of education in informed consent with clinician training, the co-production of accessible information resources and further inclusive research into informed consent for people with intellectual disability. Related reading on the hub: Accessible patient information: a key element of informed consent
  22. Content Article
    The USA National Nurses United is proposing for minimum, mandated, nurse-to-patient staffing ratios to protect patients’ right to nursing care. Every patient deserves a single standard of high-quality care. The ratios, coupled with nurses’ powerful voice of advocacy secured in collective bargaining, protect patients from complications that arise from missed care such as medical errors, health care disparities, infections, and so much more.
  23. Event
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    Integrated care systems (ICSs) have the potential to radically transform health and care through collaboration, long-term thinking, and by pushing the boundaries of what is possible. In this summit, we give voice to innovative thinking and practices by hearing from senior leaders and partners from both within and outside of the health and care service, who have found ways to create meaningful impact by doing things differently. Be inspired by leaders who despite challenging circumstances and a backdrop of a 30% reduction in running costs have carved out opportunities for collaboration to create transformational change. Join us at this event to be at the forefront of discussions and debate on how ICSs can work differently to meet the needs of their local populations and fulfil their original purpose. Through keynote speeches, panel debates, case studies and interactive workshops, this summit will explore: how we meet the potential of ICSs to transform health and care the importance of focusing on prevention as a way of sustainably meeting the needs of local populations, and the role data has in it how provider collaboratives and Integrated Care Boards (ICBs) can work together differently and effectively to deliver integrated care services how reconvening community services so that care is moved closer to home can potentially transform the health and care system the value of working with patients and communities to provide better services how system-wide solutions can be utilised to tackle the workforce crisis what leading in uncertainty feels like and what can be learnt from it. Register
  24. News Article
    The family of an autistic teenager who died from an accidental overdose say they had to investigate the death themselves to find the truth of how he died. Will Melbourne, 19, was found dead at his Cheshire home on December 18, 2020 after he mistakenly had taken a strong synthetic opioid 100 times stronger than morphine he bought on the dark web. The inquest into Will's death took three years to come back and his family say had to investigate the matter themselves to find out what happened. Sally and John Melbourne said their lives were put on hold during the long wait for the inquest to be completed and the family were told at the pre-inquest hearing that the court were short-staff and had a backlog of 500 cases. Parents and friends of the teenager used a trail of digital "breadcrumbs" to uncover that Will had tried to buy oxycodone, a highly addictive opioid that helps with pain relief and anxiety, which turned out to be a synthetic opioid. The blue pills Will had bought on the darknet were found beside his body. The family say the drugs were not tested until they raised it with the coroner's court a year after his death. Will's blood sample had also been destroyed after the company storing it went into administration. The family said they were left traumatised by the time the inquest was concluded. Mrs Melbourne said: "We thought the inquest system was there to give us answers. Instead, we felt blocked at every turn. "It was outrageous that we had to take the investigation on ourselves." Read full story Source: Mail Online, 4 January 2023
  25. Content Article
    The Medicines and Healthcare products Regulatory Agency (MHRA) has published a roadmap which outlines the intended timelines for delivering the future regulatory framework for medical devices.
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