Jump to content
 View Profile  See their activity

  • Posts

    11,906

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

Everything posted by Patient Safety Learning

  1. News Article
    People in some more rural areas are missing out on specialist treatments they should be getting, while Londoners are receiving a lot more than their “fair share”, new NHS England figures suggest. NHS England has suggested the main cause is “systematic shortfalls in access [in] remote communities”, leaving “unmet need” for specialised services in these areas. However other factors, including coding and reporting practices, year-to-year fluctuation, and weaknesses in the formula, are also likely to be confusing the picture, sources said. The variation is being uncovered now because NHSE is preparing to fund many specialised services via allocations to integrated care boards. These allocations will be based on estimates of their populations’ healthcare needs, rather than NHSE negotiating payments directly with provider trusts – as it has since 2013. Read full story (paywalled) Source: HSJ, 3 January 2023
  2. Content Article
    In this episode, Ruth Robertson explores how the NHS elective care waiting list can be managed in a way that improves health equity with Dr Mark Ratnarajah, UK Managing Director at C2-Ai, Sharon Brennan, Director of Policy and External Affairs at National Voices and Dr Polly Mitchell, Post Doctoral Research Fellow in Bioethics and Public Policy at King’s College London.
  3. Event
    until
    The health and care system continues to face profound challenges, whether it’s staff shortages, financial pressures, all-time low public satisfaction, or record high waiting times for elective care. At this free online event, our expert panel will provide insight and context into the wider health and care landscape, the challenges the sector is facing, and the big issues they want to see progress on in 2024. In the run-up to the anticipated general election, our panel will also explore how recent trends, political parties’ policy proposals and future developments could affect those working in the sector, as well as people, patients and communities. Join the discussion and share your comments and questions about the wider challenges and opportunities facing the health and care sector. Register
  4. Content Article
    Antimicrobial agents, such as antibiotics, are essential to treat some human and animal infectious diseases. Antimicrobial resistance (AMR) occurs when microorganisms change so that they are no longer affected by antimicrobial drugs used to treat them. There are different types of antimicrobials, which work against different types of microorganisms, such as antibacterials or antibiotics against bacteria, antivirals against viruses, and antifungals against fungi. Antimicrobials are often used incorrectly. The development of resistance is accelerated by the inappropriate use of these drugs, for example, using antibiotics (which help to treat bacteria) for viral infections like flu, or as a growth promoter in agriculture. Because of growing resistance, the world is running out of effective antibiotics to treat infectious diseases. Unless appropriate action is taken, decades of progress in health and medicine risk being undone. In May 2015, the World Health Assembly (WHA) endorsed a global action plan on AMR and urged all WHO Member States to develop national action plans (NAPs). The Seventy-third session of the WHO Regional Committee for Europe launched the new European roadmap on AMR (2023–2030) to help accelerate the implementation of national strategies on AMR. The new brief from WHO Regional Office for Europe highlights the important connections between AMR infection prevention and control.
  5. Content Article
    This article provides an overview of the proposed Patient Safety Structural Measure on the Centers for Medicare and Medicaid Services (CMS) list of Measures Under Consideration (MUC) 2023 and summarises the public comment submitted by Patient Safety Learning on this.
  6. News Article
    Stroke patients in England are waiting an average of almost seven hours for a specialist bed, double the wait reported before Covid. National performance against key measures collected by the Sentinel Stroke National Audit Programme has nosedived, with patients in England waiting an average of almost seven hours to be admitted to a specialist unit in 2022-23, compared to three and a half hours in 2019-20. NHS England guidance states that every patient with acute stroke should be given rapid access to a stroke unit within four hours. This time frame is considered critical, as patients can only be given clot-busting drugs, and treatments such as thrombectomy, which surgically removes a clot, within the first few hours of stroke onset. However, this was achieved in just 40% of cases last year (2022-23), down from 61% in 2018-19. Juliet Bouverie, CEO of the Stroke Association, urged ministers to give trusts what they needed to reverse the decline, saying: “Stroke is a medical emergency and every minute is critical. “We are very concerned to see that, far from improving over the last year, the proportion of stroke patients being admitted to a stroke ward within the timescale for thrombolysis has continued to decline. This is putting patient recoveries at risk and strain on the rest of the health system. “We believe that early supported discharge, when done correctly, with adequately resourced community teams, can help to alleviate capacity pressures in acute stroke units. However, this is not a silver bullet. There are longstanding workforce issues which are affecting patient flow in, through and out of stroke units and we call on DHSC to properly address these in the workforce plan.” Read full story (paywalled) Source: HSJ, 2 January 2024
  7. News Article
    Patients who feel fortunate to get a doctor's appointment then find they are in and out of the GP surgery in less than five minutes. A fifth of the consultations in England last year were done within that time. Dennis Reed, of the Silver Voices campaign group for over-60s, said: "It is hard enough to get a face-to-face appointment with a GP these days, without being shown the door before you have had a chance to take your coat off. "The public wants the family doctor back, who knows your family history and has the time to chat about your general health and wellbeing. "A revolving door policy, with the patient exiting after a couple of minutes clutching a prescription, is not the way to run a primary care service." Research from the House of Commons Library, commissioned by the Lib Dems, found 22% of GP appointments between January to October 2023 lasted five minutes or less. Lib Dem MP Wera Hobhouse said: "Seeing a GP is the most vital contact for people to address their health concerns, seek help and start treatment. "Not having quick and easy access to a GP and not having sufficient time for patients during an appointment leads to huge problems later on, let alone the anxiety and additional pain people suffer because of delays." Read full story Source: The Express, 31 December 2023
  8. News Article
    Hundreds of children’s appointments – including for lifesaving operations and cancer treatments – have been cancelled on each day that NHS strikes took place over the last year, as hundreds of thousands of youngsters languish on the waiting list for treatment, The Independent can reveal. More than 20,000 paediatric treatments and surgeries were shelved because of the walkouts, while the families of 400 children were told that their lifesaving operations had been cancelled. With junior doctors due to stage the longest strike in NHS history this week – for six days, starting on Wednesday – the problem is set to get worse. Dr Camilla Kingdon, president of the Royal College of Paediatrics and Child Health, warned that long waits for children can be particularly damaging, and can have a lifelong impact as treatment is often time-critical. She said that children are seldom prioritised in national policy-making, and urged the government to put children’s needs “back on the agenda”. Read full story Source: The Independent, 2 January 2024
  9. Content Article
    Sentinel Event Alert newsletters identify specific types of sentinel and adverse events and high risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences. Accredited organisations should consider information in a Sentinel Event Alert when designing or redesigning processes and consider implementing relevant suggestions contained in the alert or reasonable alternatives.
  10. News Article
    An alarming number of Britons are turning into “DIY doctors” because of the struggle to get an NHS GP appointment in 2023, new polling has revealed. Some 23% of those surveyed said they could not get an appointment, while three in 10 (33 per cent) said they had given up on booking one altogether, according to a Savanta poll commissioned by the Liberal Democrats. Many said they had resorted to “DIY” medical care or gone to A&E instead. One in seven (14 per cent) said they had been forced to treat themselves or ask someone else untrained to do so, with the same proportion seeking emergency care. One in five people said they had bought medication online or at a pharmacy without advice from a GP, and one in three had delayed seeing a doctor despite being in pain, as pressure on the NHS mounts. Liberal Democrat leader Sir Ed Davey described the figures as “utterly depressing” and said they should serve as an “urgent wake-up call for ministers asleep on the job”. Read full story Source: The Independent, 1 January 2024
  11. Content Article
    Rob Behrens reflects on the work the Parliamentary and Health Service Ombudsman (PHSO) has done over the last year to drive improvements in patient safety.
  12. Content Article
    The BMA has sent a letter to Amanda Pritchard, Chief Executive of NHS England, highlighting the increasing concerns from their members about the protection of healthcare workers and patients from Covid-19, particularly in light of the rise in cases, hospitalisations and deaths that occurred in September and October. 
  13. News Article
    NHS bosses fear patient safety could be compromised during this week’s junior doctors strikes if medics do not honour an agreement to abandon picket lines if hospitals become overwhelmed during the winter crisis. Hospital bosses can ask the British Medical Association (BMA) to allow junior doctors to return to work to help if an emergency arises during their six-day strike starting on Wednesday. But there is concern among health trust leaders that the doctors’ union could reject such “recall requests” – or take worryingly long to consider them – despite “highly vulnerable” hospitals having too few staff on duty to cope with a surge in patient numbers. A spike in cases of flu, Covid and norovirus has left the NHS under intensifying strain in the first week of the new year, a period in which its winter crisis often bites. On the eve of the 144-hour strike – the longest in NHS history – the NHS Confederation, which represents trusts, urged the BMA to ensure the “recall system” worked reliably if it was triggered. “With the next round of junior doctors strikes coinciding with what is always an exceptionally busy week for the NHS, health leaders hope that escalation plans run smoothly and with a shared understanding that protecting patient safety is the most important priority,” Danny Mortimer, the confederation’s deputy chief executive, said. Read full story Source: The Guardian, 1 January 2024
  14. News Article
    Nurses are being put in increasing danger from shocking levels of violence and aggression by patients, a senior nursing leader has warned. Prof Nicola Ranger, the Royal College of Nursing’s (RCN) director of nursing, said the crisis in the NHS had fuelled bad behaviour by patients frustrated by worsening delays for treatment since the Covid pandemic. Ranger said the situation was contributing to an exodus of nurses from the NHS, amid a vicious cycle of staff shortages and rising violence. This meant that there were often not enough nurses on duty to keep colleagues safe, she added. Calling on the government to make tackling the abuse of nurses a priority, Ranger said there was a sense of despair in the profession about their deteriorating working conditions. “I think the public would be totally shocked if they knew how common it is for nursing staff to be on the receiving end of violence and aggression at work,” said Ranger. “Nurses are put in jeopardy, it’s become all too common for them to be threatened by patients on shift. “We genuinely have got a nursing crisis in the UK that doesn’t seem to be being acknowledged by our government at all. Being spat at, being hit, being punched, can for some nurses just literally be the final straw." Read full story Source: The Guardian, 1 January 2024
  15. News Article
    Hospital admissions from a winter virus could be reduced by more than 80% if babies are given a single dose of a new antibody treatment, a study says. Respiratory syncytial virus (RSV) usually causes mild, cold-like symptoms, but can lead to bronchiolitis and pneumonia. More than 30,000 under fives are hospitalised with RSV in the UK annually, resulting in 20 to 30 deaths. One British parent said her son getting RSV was "very scary" as a first-time mother. Lorna and Russell Smith's eldest son, Caolan, got the virus when he was eight months old and was admitted to hospital twice - each time requiring oxygen. Now aged two, he has made a full recovery. "I hadn't heard of RSV and wasn't sure what to do. He had laboured breathing due to high temperature and was quite lethargic. It brought a lot of anxiety and stress," Lorna said. The Harmonie study involved 8,000 children up to the age of 12 months, with half receiving a single dose of the monoclonal antibody treatment nirsevimab. The results, published in the New England Journal of Medicine, showed that RSV-related hospitalisation was reduced by 83% in those receiving the jab and admissions for all chest infections were cut by 58%. Side effects were similar in both groups and mostly mild. Read full story Source: BBC News, 27 December 2023
  16. Content Article
    The US Food and Drug Administration (FDA) list of drug names with recommended tall man (mixed case) letters was initiated in 2001 with the agency’s Name Differentiation Project. Tall man lettering (TML) is a technique that uses uppercase lettering to help differentiate look-alike drug names. Starting on the left side of a drug name, TML highlights the differences between similar drug names by capitalizing dissimilar letters (e.g., vinBLAStine versus vinCRIStine and CISplatin versus CARBOplatin). TML can be used along with colour or bolding to draw attention to the dissimilarities between look-alike drug names, and alert healthcare providers that the drug name can be confused with another drug name. The Institute for Safe Medication Practices (ISMP) 'Look-alike drug names with recommended tall man (mixed case) letters' contains drug name pairs or larger groupings with recommended, bolded uppercase letters to help draw attention to the dissimilarities in look-alike drug names. The list includes mostly generic-generic drug names, although a few brand-brand or brand-generic names are included.  See also our Medication error traps gallery
  17. Event
    This national conference looks at the practicalities of Serious Incident Investigation and Learning from Deaths in Mental Health Services and implementation of the New Patient Safety Incident Response Framework (PSIRF previously known as the Serious Incident Framework). The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework. To register go to https://www.healthcareconferencesuk.co.uk/virtual-online-courses/investigation-of-deaths-serious-incidents-in-mental-health-services or email frida@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow the conference on Twitter @HCUK_Clare #SIMental
  18. Content Article
    That safety is paramount in healthcare goes without saying. There are though variations in patient outcomes between hospitals that cannot be explained by different population characteristics. Based on aggregate staffing data, a number of studies have shown that skill mix can be a factor accounting for these variations – essentially the higher the ratio of unregistered staff to registered staff the greater the incidence of adverse outcomes including mortality rates. Professor Richard Griffin explores this further in his LinkedIn article.
  19. News Article
    Hospital neglect contributed to the death of a two month old baby after staff turned off emergency alarms, a coroner has ruled. Louella Sheridan died at Royal Bolton Hospital in on 24 April 2022 after she was admitted with bronchiolitis to the hospital’s intensive care unit before later dying from Covid and a related heart condition. Four alarms on a monitoring machine were silenced and then switched off before the baby collapsed in a high dependency unit, it has been found. On Wednesday coroner John Pollard ruled neglect by staff had contributed to Louella’s death after staff switched off the alarms on the monitors attached to her during the night. Summing up his conclusion Coroner Pollard reportedly said there was a “gross failure “ to provide basic medical care to Louell and that had care been given, had the alarms been switched on to alert staff her life may have been extended at least for a short period of time. He said turning off the alarms was a gross type of conduct. Read full story Source: The Independent, 22 December 2023
  20. News Article
    Patients have been harmed as a result of doctors striking this year, and others needing time-critical treatment will be at risk during next month’s walkout in England, hospital bosses have said. Cancer patients and women having induced or caesarean section births will be in danger of damage to their health unless junior doctors in those areas of care abandon their plans to strike for six days in January, they said. People awaiting urgent eye surgery risk permanent sight loss unless the British Medical Association (BMA) lets junior doctors keep working in that area, according to NHS Employers, which represents health service trusts in England. Its intervention comes amid mounting concern in the NHS that it may prove impossible to maintain patient safety in high-risk, time-sensitive areas of treatment when tens of thousands of junior doctors stage what will be the longest strike in NHS history from 3 January, when hospitals are facing what is often the service’s busiest week of the year. Read full story Source: The Guardian, 21 December 2023
  21. Content Article
    This report from the NHS Confederation explores practical shifts towards population health and population health management approaches.
  22. Content Article
    These role requirements documents for Patient Safety Specialists at providers and Integrated Care Boards (ICBs) are designed to support NHS organisations in identifying individuals with the right skills and experience to take on the role as a Patient Safety Specialist. They outline the purpose of Patient Safety Specialists, the key requirements of the role, and how we expect them to work in their own organisation, as well as with local, regional and national partners. There are separate versions of the document for Patient Safety Specialists at NHS providers and at ICBs.
  23. Content Article
    Efforts to increase physician engagement in quality and safety are most often approached from an organisational or administrative perspective. Given hospital-based physicians’ strong professional identification, physician-led strategies may offer a novel strategic approach to enhancing physician engagement. It remains unclear what role medical leadership can play in leading programmes to enhance physician engagement. In this study, Rotteau et al. explore physicians’ experience of participating in a Medical Safety Huddle initiative and how participation influences engagement with organisational quality and safety efforts. They found that The Medical Safety Huddle initiative supports physician engagement in quality and safety through intrinsic motivation. However, the huddles’ implementation must align with the organisation’s multipronged patient safety agenda to support multidisciplinary collaborative quality and safety efforts and leaders must ensure mechanisms to consistently address reported safety concerns for sustained physician engagement.
  24. Content Article
    In the UK and several other countries, including Norway, Australia and New Zealand, operators of safety-critical systems, such as nuclear power plants, public transportation systems and defence equipment, must develop a safety case to demonstrate that their systems are acceptably safe to operate. In these countries, the development, review and maintenance of safety cases are regulatory requirements. In the NHS in England, manufacturers of health information technology have been required to submit clinical safety cases since 2013. However, this is a domain with a narrow technological focus and limited organisational support.  Mark Sujan and Ibrahim Habli discuss why they think safety cases would be a valuable addition to Safer Clinical Systems and patient safety practice?
  25. News Article
    Nearly 1.7 million Texans have lost their health insurance — the largest number of people any state has removed — in the months since Texas began peeling people from Medicaid as part of the post-pandemic “unwinding.” Around 65% of these removals occurred because of procedural reasons, according to the state. Texas’ Health and Human Services Commission has neared the end of a chaotic and overburdened process to remove people from state Medicaid insurance who became ineligible during the coronavirus pandemic. The state had not unenrolled people before this year because of federal pandemic rules, which forbid states from cutting coverage. As a result, more than 5 million Texans had continuous access to healthcare throughout the pandemic through Medicaid, the joint federal-and-state-funded insurance program for low-income individuals. In Texas, the program’s eligibility criteria is so restrictive, it mainly covers poor children, their mothers while pregnant and post partum, and disabled and senior adults. But the effects of speedrunning this process have reverberated: Still-eligible Texans were kicked off both in error and for procedural reasons, adding to backlogs of hundreds of thousands of Medicaid applications and pushing wait times back several months. “The state handled this with an incredible amount of incompetence and indifference to poor people,” U.S. Rep. Lloyd Doggett, D-Austin, told The Texas Tribune. “It's really appalling.” Read full story Source: The Texas Tribune, 14 December 2023
×
×
  • Create New...