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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    This study published in the BMJ found that women with clinically diagnosed perinatal depression were associated with an increased risk of death, particularly during the first year after diagnosis and because of suicide. Women who are affected, their families, and health professionals should be aware of these severe health hazards after perinatal depression.
  2. Content Article
    Derek Richford’s grandson Harry died in November 2017 at just a week old. Since Harry’s death, Derek has worked tirelessly to uncover the truth about what happened at East Kent Hospitals University Foundation Trust (EKHUFT) to cause Harry’s death.  In a blog published on the Making Families Count website, Derek explores some aspects of how the family's complaints were handled. Further reading on the hub: “Getting the hospital to be honest with us felt like a battle from day one.” An interview with Derek Richford
  3. Content Article
    The objective of this systematic review from Benhamou et al. was to assess the clinical, economic, and health resource utilisation outcomes associated with the use of prefilled syringes in medication administration compared with traditional preparation methods. The findings provide new insights into clinical and economic benefits of prefilled syringe adoption. These benefits include improved medication delivery and safety, which can lead to time and cost reductions for health care departments, hospitals, and health systems. However, further real-world research on clinical and economic outcomes, especially in contamination, is needed to better understand the benefits of prefilled syringes.
  4. Content Article
    Recording of the European Patient Safety Foundation conference which took place on the 17 November in Vienna, Austria.
  5. News Article
    The former nursing director at the hospital where Lucy Letby murdered seven babies will be among the 'core participants' of the Thirlwall Inquiry. The inquiry, chaired by Lady Justice Thirlwall, will investigate how Letby was able to commit the murders and attempt six others while she worked as a neonatal nurse at Countess of Chester Hospital NHS Foundation Trust in 2015 and 2016. This week, Alison Kelly, who was director of nursing and quality at the trust during the time of Letby's crimes, was announced as 1 of 10 core participants in the inquiry. Also named were former Countess of Chester chief executive Tony Chambers, former medical director Ian Harvey and former human resources director Sue Hodkinson. Ms Kelly and Mr Harvey were among the senior staff at the trust who were accused of failing to act when clinicians first raised concerns about Letby. How managers responded to such concerns is one of the areas due to be investigated by the Thirlwall Inquiry. A number of organisations are also on the list as core participants, including the Nursing and Midwifery Council (NMC), NHS England, the Royal College of Paediatrics and Child Health, the Department of Health and Social Care and Countess of Chester itself. Read full story Source: Nursing Times, 3 January 2024
  6. News Article
    More NHS managers support regulation of their roles than oppose it, despite many fearing its implementation will be unfair or disproportionate, a survey suggests. The trade union Managers in Partnership surveyed NHS managers working at Agenda for Change band 8a and above throughout the UK late last year, collecting 291 responses. Asked whether they “in principle… support professional regulation of NHS managers”, 49% said they supported or strongly supported it. Just 19% said they opposed or strongly opposed, while the remainder were neutral. However, respondents – 22% of whom said they were already covered by a professional regulator, and likely to be nurses, doctors or finance or legal professionals – appeared sceptical about the benefits. Asked whether they thought professional regulation of NHS managers would make processes for raising concerns/whistleblowing better or worse, only 26% said it would be better. 20% said these would get worse, and the remainder said it would be “about the same”. Read full story (paywalled) Source: HSJ, 9 January 2023
  7. Content Article
    The NHS remains under immense pressure. Each part of the system is experiencing demand beyond its capacity, which is continually increasing the problem. This is most vividly illustrated in urgent and emergency care settings. Each winter in the past decade has become slightly worse,2 and that trend, which has not been reversed, has resulted in a dire situation that may not yet have reached its nadir. A continuum of often predictable perfect storms has caused a struggling system to reach collapse, writes Tim Cooksley, immediate past president, Society for Acute Medicine in this BMJ opinion piece.
  8. News Article
    The senior midwife tasked by the government and NHS to investigate serious maternity scandals has warned that new mothers are being driven to suicide and backed an MP’s review into birth trauma. Donna Ockenden said it was “appalling” that women who should be in the “happiest times of their lives” were taking their own lives, after it was found suicide was the leading direct cause of deaths up to 12 months after giving birth. Ockenden, who has exposed poor maternity care across the country, is preparing to give evidence to an inquiry launched by Theo Clarke, the Conservative MP for Stafford, on birth trauma. Clarke thought she was going to die after giving birth to her daughter Arabella last year, having suffered a third-degree tear. But it was the lack of help available that opened her eyes to the estimated 200,000 women a year who experience birth trauma. Ockenden told The Times she had “huge respect” for Clarke’s inquiry and said: “I think that this whole issue of maternal trauma, sometimes long-term psychological trauma for families as well post a difficult maternity experience, is not necessarily given enough air time.” Read full story (paywalled) Source: The Times, 8 January 2023
  9. News Article
    A coroner overseeing a teenager's inquest has warned there will be more deaths unless mental health services improve for autistic people at risk of self-harm. Morgan-Rose Hart, 18, who had ADHD, autism and a history of mental illness had been a patient at a unit in Harlow, Essex, for three weeks. An inquest jury concluded she died by misadventure contributed to by neglect. Ms Hart, from Chelmsford, died in hospital six days after she was found unresponsive in the bathroom of her mental health accommodation in the Derwent Centre in Harlow, Essex in July 2022. The inquest into her death heard staff observations were falsified and critical observations were missed. In her Prevention of Future Deaths report, Ms Hayes said: "There is a significant shortfall of appropriate placements for people with autism who have mental health and self-harm risks in Essex both inpatient and in the community." She added: "During the course of the inquest the evidence revealed matters giving rise to concern. "In my opinion, there is a risk that future deaths will occur unless action is taken." Read full story Source: BBC News, 8 January 2024
  10. News Article
    A former midwife has told the BBC she quit because she could not live with herself if she provided poor care. Hannah Williams says staff shortages meant she kept patients safe, but sometimes only "by the skin of her teeth". BBC Verify analysis shows that the number of full-time equivalent midwife posts in England has gone up by 7% in the last decade. In comparison, the overall NHS workforce has increased by 34%. The country has a shortage of about 2,500 midwives, and maternity units are struggling with safety concerns. BBC research has also found that some trusts have more than one in five midwife jobs unfilled. The Royal College of Midwives says staffing is the "most important issue" and the gap needs to close. Read full story Source: BBC News, 9 January 2024
  11. Content Article
    Patient safety is a US national priority, yet lacks a comprehensive assessment of progress over the past decade. The aim of this study from Eldridge et al. was to determine the change in the rate of adverse events in hospitalised patients. The study found that in the US between 2010 and 2019, there was a significant decrease in the rates of adverse events abstracted from medical records for patients admitted for acute myocardial infarction, heart failure, pneumonia, and major surgical procedures, and there was a significant decrease in the adjusted rates of adverse events between 2012 and 2019 for all other conditions. Further research is needed to understand the extent to which these trends represent a change in patient safety.
  12. News Article
    NHS England and government are set to raise their target for four-hour A&E performance, despite most hospitals failing to meet the current ask. HSJ understands officials are likely to use 2024-25 planning guidance to raise the “interim” target for four-hour performance from the 76% which trusts were asked to hit in 2023-24. A new objective of 80% by March 2025 has been discussed, several sources said, but is not confirmed. The 76% target has not been met during any month of 2023-24 so far, and most acute trusts are consistently falling well short of it. Well-placed sources told HSJ the target was likely to be increased despite “some doubts” among senior NHSE officials. One senior NHSE source said: “The target should be increasing incrementally as overall NHS A&E performance improves, [but] it hasn’t really improved this year.” Read full story (paywalled) Source: HSJ, 5 January 2024
  13. Content Article
    A new guide to innovation implementation, readiness and resourcing has been published sharing practical learning from the Health Innovation Network’s successful adoption and spread of the national Focus ADHD programme. 
  14. Content Article
    The maternal mortality rate (MMR) in the United States continues to increase despite medical advances and is exacerbated by stark racial disparities. Black women are disproportionately affected and are three times more likely to experience a pregnancy-related death (PRD) compared to Non-Hispanic White (NHW) women. Keisha E. Montalmant and Anna K. Ettinger carried out a literature review to examine the racial disparities in the United States' MMR, specifically among pregnant Black women. The review highlights that maternal health disparities for Black women are further impacted by both structural racism and racial implicit biases. Cultural competence and educational courses targeting racial disparities among maternal healthcare providers (MHCP) are essential for the reduction of PRDs and pregnancy-related complications among this target population. Additionally, quality and proper continuity of care require an increased awareness surrounding the risk of cardiovascular diseases for pregnant Black women.
  15. News Article
    At least 38 babies died in the space of nine years after serious incidents in the country’s maternity units, it has emerged. The total is based on research of both media reports of inquests and settled claims. Before Christmas, a review by the Irish Examiner revealed 21 hospital baby deaths followed one or more serious incidents, between 2013 and 2021. However, further study in the same nine-year period shows the toll to be higher. The worst year was 2018, when not only did at least 10 babies die, but three of them died at the same Dublin hospital over a five-month period. In at least 18 of the 38 deaths, issues around foetal heartbeat monitoring (CTG) were raised either at inquest or in the High Court. At least 18 of the inquests resulted in a verdict of medical misadventure. As well as issues around heart monitoring, the Irish Examiner review shows that in at least seven of the 38 cases, maternity staff missed signs that a woman was in labour, leading to repeated recommendations around training. In at least seven cases, mothers’ concerns were ignored. Read full story Source: Irish Examiner, 29 December 2023
  16. News Article
    Patients' lives are being put at risk because it is too easy to buy prescription-only medicines from online pharmacies, a leading pharmacist says. A BBC investigation found 20 online pharmacies selling restricted drugs without checks - such as GP approval. In total, over 1,600 various prescription-only pills were bought during the investigation entering false information without challenge. Regulator the General Pharmaceutical Council says extra checks are needed when selling some drugs online. The BBC's findings highlight the "wild west" of buying medicines on the web, says Thorrun Govind, a pharmacist, health lawyer and former chair of the Royal Pharmaceutical Society. "The current guidance basically tells pharmacies to be robust, but do that in your own way, and we know that under this current system, patients have died," she says. The parents of a woman who died in 2020, after accidentally overdosing on medicines she bought online, are among those calling for stricter rules. Katie Corrigan, from St Erth in Cornwall, had developed an addiction to painkillers after experiencing neck pain. "Katie needed help, she didn't need more medication," says her mum, Christine Taylor. Her GP had stopped supplying the drug after realising she had been allowed to request new prescriptions prematurely and been prescribed too much. Instead, Katie, 38, was able to buy a painkiller and a drug used to treat anxiety from multiple online pharmacies without notifying her GP. The coroner at Katie's inquest confirmed her GP had not been contacted by any of the pharmacies to check the drug was safe for her. In his final report, he said the safety controls were inadequate. Read full story Source: BBC News, 5 January 2024
  17. News Article
    The NHS will start recording harm caused to patients during strike action where exemptions have been rejected by the British Medical Association (BMA). BMA council chair Phillip Banfield yesterday accused NHS England of the “weaponisation” of the strike “derogation” process, saying trusts had this week submitted more of the requests, which would permit some striking doctors to return to work, and were not providing information needed to determine if they were justified. NHS England wrote back to Professor Banfield, insisting it was only trying to prioritise safety, but also saying it would revise its own approach to derogation requests. This will include: asking trusts whose requests were rejected by the BMA “to compile a picture” of the impact on services; reinforcing requirements to report patient safety incidents during strikes and after mitigation requests, so “we can evidence harm and near misses which might have been avoided”. The letter says: “We have consistently asked local medical and other clinical leaders to consider applying to the BMA for patient safety mitigations where they have significant concerns for patient safety that cannot be mitigated through other options available to them, and where they can make a strong evidential case that the return of a limited number of junior doctors would address these risks. “We have done this, in part, because we have received a number of reports over previous periods of action that some teams have been put off seeking patient safety mitigations because of their prior experience of having applications rejected, or not receiving a response in time. We are sure you would agree that this is an unsatisfactory position, and that where patient safety concerns exist, these should always be escalated appropriately.” Read full story (paywalled) Source: HSJ, 4 January 2024
  18. Content Article
    In 2021 in New South Wales (NSW) there were 41,619 people over 65 who were hospitalised due to a fall at home or in the community. This number increased by 60% in a decade from 25,982 in 2010 and the incidence of falls is set to increase further as the population ages. In 2021 the cost to the NSW health system from falls by older people in the community was around $752 million. These costs are projected to grow to $1.09 billion by 2041 – the result of around 60,300 hospitalised falls projected for that year. There is robust evidence that falls can be prevented. Fall prevention is a complex area as there are multiple risk factors that may contribute as to why a person may fall. A systems thinking approach acknowledges the complexity of fall prevention, seeks to understand the interactions between components, and identifies what interventions work best.
  19. Content Article
     The World Health Organization (WHO) has shared a list of key milestones in their Global Patient Safety Journey during 2023.
  20. Content Article
    Interprofessional communication is of extraordinary importance for patient safety. To improve interprofessional communication, joint training of the different healthcare professions is required in order to achieve the goal of effective teamwork and interprofessional care. The aim of this pilot study from Heier et al. published in BMC Medical Education was to develop and evaluate a joint training concept for nursing trainees and medical students in Germany to improve medication error communication.
  21. Content Article
    Prisoners have a right to the same standards of healthcare available to people in the community, and although we might suspect that people in prisons don't always receive the care they need, this is a difficult issue to get at through research. So how can we meaningfully compare hospital use between those in prison and those who are not? Miranda Davies and Eilís Keeble used a novel matched control methodology to show that prisoners use services less than people with similar health characteristics who are not incarcerated.
  22. Content Article
    The Royal College of Nursing (RCN) held its first ever safe staffing summit, bringing together global nursing workforce experts with senior nurses across the UK to agree a vision for the future and how to fight for it.   When there are too few nursing staff, they can be stretched dangerously thin. With tens of thousands of vacant nurse posts across the UK right now, this happens too often. The summit heard compelling evidence about the impact of safe nurse-to-patient ratios, set in law in other countries, where there are limits on the number of patients one nurse can safely care for.  Nicola Ranger, RCN's Chief Nurse, reflects on the outcome of the RCN’s first ever safe staffing summit.
  23. News Article
    The Welsh Ambulance Service is struggling to cope as many A&E departments are full and some patients have reportedly been waiting to be offloaded from ambulances for as long as 15 hours. The service has issued a plea for the public to "use 999 responsibly" amid severe pressure. An employee of the service said: "Nearly every A&E department is at capacity. Patients have been on ambulances for the last 15 hours. The ambulance service is only responding to red [immediately life-threatening] calls." The service has received almost 13,000 calls to 999 since Boxing Day and there have been almost 36,000 calls to the NHS 111 Wales service. Lee Brooks, the ambulance service’s operations boss, said: “Pent-up demand from the Christmas and New Year period, coupled with the seasonal illnesses we see at this time of year, means there are lots of people across Wales trying to access health services currently. When hospitals are at full capacity, it means ambulances can’t admit their patients, and while they’re tied up at emergency departments, other patients in the community are waiting a long time for our help, especially if their condition isn’t life-threatening. “We’re working really hard as a system to deliver the best possible care to patients, but our ask of the public today – and in the coming days – is only to call 999 if they are seriously ill or injured, or where there is an immediate threat to someone’s life. That’s people who’ve stopped breathing, people with chest pain or breathing difficulties, loss of consciousness, choking, severe allergic reactions, catastrophic bleeding or someone who is having a stroke." Read full story Source: Wales Online, 3 January 2024
  24. News Article
    Trusts reduced the number of 65-week breaches by around 20% and cut the overall elective waiting list between October and mid-December, NHS England has said. The claim is based on provisional data published by NHSE on 2 January, which came with a warning of possible “significant issues regarding the quality and completeness”. The figures suggest the number of 65-week waiters fell from around 114,000 on 8 October to around 93,000 by 17 December. The last official “referral to treatment” figures were published last month (see table below). They reported there were around 107,000 65-week breaches in October. Sources familiar with the provisional data, from the “waiting list minimum data set”, said while it was not as accurate as official referral to treatment statistics, it gives an accurate picture of the direction of travel and overall performance. Read full story (paywalled) Source: HSJ, 3 January 2024
  25. News Article
    NHS England has been accused of bowing to political pressure and trying to “undermine” the junior doctors strike. British Medical Association council chair Philip Banfield tonight wrote to NHSE chief executive Amanda Pritchard accusing her organisation of the “weaponisation” of the process used to agree minimum services level during the strike. Junior doctors walked out yesterday to begin a six day strike, the latest in their 10 month campaign and the longest in NHS history. Professor Banfield’s letter claims that NHSE is not respecting the terms of the voluntary agreement to provide “derogations”. These, says the letter, “allow for junior doctors to return to work in the event of safety concerns arising from ‘unexpected and extreme circumstances’ unrelated to industrial action”. The BMA accuses trusts of not providing the information the union needs to determine if the requests for derogations are justified. It said that the lack of information provided by trusts had led to it turning down 20 requests for derogations. The letter states: “We are increasingly drawing the conclusion that NHS England’s change in attitude towards the process is not due to concerns around patient safety but due to political pressure to maintain a higher level of service, undermine our strike action and push the BMA into refusing an increasing number of requests; requests, we believe, would not have been put to us during previous rounds of strike action. “The change in approach also appears to be politicisation and weaponisation of a safety critical process to justify the Minimum Service Level regulations.” Read full story (paywalled) Source: HSJ, 3 January 2024
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