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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Many healthcare improvement approaches originated in manufacturing, where end users are framed as consumers. But in healthcare, greater recognition of the complexity of relationships between patients, staff, and services (beyond a provider-consumer exchange) is generating new insights and approaches to healthcare improvement informed directly by patient and staff experience. Co-production sees patients as active contributors to their own health and explores how interactions with staff and services can best be supported. Co-design is a related but distinct creative process, where patients and staff work in partnership to improve services or develop interventions. Both approaches are promoted for their technocratic benefits (better experiences, more effective and safer services) and democratic rationales (enabling inclusivity and equity), but the evidence base remains limited. This Element explores the origins of co-production and co-design, the development of approaches in healthcare, and associated challenges; in reviewing the evidence, it highlights the implications for practice and research.
  2. Content Article
    The Belmont Report was written by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Commission, created as a result of the National Research Act of 1974, was charged with identifying the basic ethical principles that should underlie the conduct of biomedical and behavioral research involving human subjects and developing guidelines to assure that such research is conducted in accordance with those principles. Informed by monthly discussions that spanned nearly four years and an intensive four days of deliberation in 1976, the Commission published the Belmont Report, which identifies basic ethical principles and guidelines that address ethical issues arising from the conduct of research with human subjects.
  3. News Article
    The NHS could struggle to cope with a catastrophic flu season after leading medics warned of plunging flu vaccine uptake among its frontline staff. NHS figures show just 39% of frontline staff had a flu vaccine in November, down from 52% in November 2020. The worrying statistics mean the already under-strain service could lose crucial staff to illnesses and risk spreading the virus during its busiest winter period. Speaking to The Independent, Dr Adrian Boyle, president of the Royal College of Emergency Medicine said: “We are concerned about staff vaccination against flu. Post-pandemic, there is a certain lack of appetite and there is probably a degree of apathy about staff getting vaccinated against flu, and we think that’s a problem. “We need to be doing more to get stuff vaccinated against flu.” He added: “I think societally and as healthcare practitioners, I think we have a moral duty to get ourselves vaccinated so we don't create gaps by going off sick and we don't infect our patients.” Read full story Source: The Independent, 21 December 2023
  4. News Article
    At least 137,000 women in the UK live with the painful and traumatic consequences of cutting, but there is no provision for reconstructive surgery. In May 2023, Shamsa Araweelo was in the A&E department of a London hospital in excruciating pain. It wasn’t the first time she had sought urgent treatment for the gynaecological damage caused by the female genital mutilation (FGM), or cutting, forced on her as a six-year-old. In fact, this was one of many such visits to emergency departments that Araweelo had made in her desperate attempt to find a surgeon who could help undo the damage done to her as a child and which has caused her so much pain and trauma as an adult. Araweelo says that in A&E she was told that she had severe nerve damage and that it could be reversed through reconstructive surgery. But not in the UK. “No doctor in the country will touch you, because you are an FGM survivor,” Araweelo says she was told. “I felt no compassion, no respect. Only in London did they tell me they wished they had the appropriate training to help me, and it breaks my heart. We are not valued in the UK.” Current NHS rules state that if a health practitioner suspects a patient has been cut, they must report the case to the police and complete a safeguarding risk assessment to determine whether a social care referral is required. Guidance for GPs also recommends referrals for mental health issues related to FGM or referrals to uro-gynaecological specialist clinics. Araweelo says that in all the years she has sought help she has never been offered any kind of support from medical professionals. Read full story Source: The Guardian, 21 December 2023
  5. Content Article
    Patient safety is a US national priority, yet lacks a comprehensive assessment of progress over the past decade. This study determined 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.
  6. Content Article
    NEWS is a tool developed by the Royal College of Physicians which improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes. In December 2017, an updated version of NEWS, NEWS2 was published. NEWS2 has been endorsed by NHS England and NHS Improvement – for use in acute and ambulance settings. NEWS2 has seen widespread uptake across the NHS in England – at present 100% of ambulance trusts and 76% of acute trusts are using NEWS2, with other early warning scores in place in other areas. However, confusion caused by the current variation in practice can compromise patient safety, something that would be eliminated by use of a common tool. Through standardisation of NEWS2, we can reduce the number of patients whose conditions deteriorate whilst in hospital, and potentially save over 1,800 lives a year.
  7. Event
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    Apollo Hospitals Group proudly announces the upcoming 11th International Patient Safety Conference, a key initiative that aligns with their mission. This conference will serve as a platform for experts, practitioners, and enthusiasts to come together, share insights, and explore innovative solutions. International Patient Safety Conference (IPSC), now in its 11th edition, is an annual event to learn from the patient safety experts across the world. It has become a powerful platform where best practices and innovations in patient safety are shared. There are many informative presentations, panel discussions, debates, paper presentations and other well-knit sessions during the conference. Register
  8. Content Article
    The aim of this project was to introduce and evaluate the Call 4 Concern© (C4C) service, which provides patients and relatives with direct access to critical care outreach services (CCOS). This allows patients and relatives an additional platform to raise concerns related to the clinical condition and facilitate early recognition of a deteriorating patient. The introduction of Call 4 Concern at a district general hospital was inspired by the Royal Berkshire Hospital, where staff have been pioneering the service in the UK since 2009. They were able to demonstrate the potential to prevent clinical deterioration and improve the patients' and relatives' experiences.  The project was originally inspired by the Condition H(elp) system in the USA, which was set up following the death of an 18-month-old child who died of preventable causes. Similar tragic cases in the USA and the UK have prompted campaigning by affected families, resulting in the widespread adoption of comparable services. The project was rolled out in the authors' trust for all adult inpatients. There was a 2-week implementation phase to raise awareness. Between 22 February 2022 and 22 February 2023, the CCOS team received 39 C4C referrals, representing approximately 2.13% of the total CCOS activity. Clinical deterioration of a patient was prevented in at least three cases, alongside overwhelming positive feedback from service users.
  9. Content Article
    An estimated 2.1 million people are living with Long Covid in the UK alone. The Conversation recently asked 888 people in the UK with Long Covid about their experiences of stigma, and 95% of them said they had experienced stigma related to their condition. On top of the physical symptoms, people living with Long Covid may have to contend with discrimination and prejudice within their communities, workplaces and even health services. Long Covid is a relatively new medical condition, and has been subject to lots of misinformation and minimisation of its legitimacy as a physical illness. To date, there have been no estimates as to how common stigma around long COVID is, which has limited our ability to tackle the problem. Being aware of numerous anecdotes of the discrimination Long Covid patients face, The Conversation decided to look into the extent of this problem and designed a questionnaire together with people who had lived experience of the illness. The questions aimed to estimate how commonly people with Long Covid experience stigma across three domains. “Enacted stigma” means being treated unfairly due to their long COVID, “internalised stigma” is where people feel embarrassed or ashamed of their illness, and “anticipated stigma” is a person’s expectation that they will be treated poorly because of their condition.
  10. Content Article
    The Patient Experience Toolkit (PET+) is an evidence-based approach to enhancing patient experience developed through research led by the Yorkshire Quality and Safety Research Group. The toolkit is a facilitator’s guide to listening to patients, and the frontline teams who deliver their care, and how to use improvement and engagement methods to support positive changes.
  11. News Article
    Thousands more elderly people will be stuck in hospital over Christmas because of junior doctors’ strikes, Age UK has warned. The charity is among several who have said the timing of the strikes, which begin at 7am on Wednesday means it will be “extremely difficult to ensure safe and effective care” during them. Age UK is one of five organisations raising fears over patient safety and making a plea to the British Medical Association (BMA) and Victoria Atkins, the Health Secretary, for a resolution to the dispute. Junior doctors’ walkouts are due to last until Saturday, with their longest strike to come early in the new year, while flu, norovirus and Covid hospitalisations are rising. In a joint letter with the NHS Confederation, Patients Association, National Voices and Healthwatch , Age UK said strike action in the days ahead could leave thousands of patients stranded in hospital for want of staff to get them discharged. The latest figures show 13,000 such cases in hospitals despite being medically fit for discharge. The charities said the withdrawal of almost half the medical workforce in England would mean the most vulnerable are left “bearing the brunt” of the pay dispute. “Our concern is that, despite the best efforts of hard-working NHS staff, it will be extremely difficult to ensure safe and effective care during this period for all patients that need it.” Read full story (paywalled) Source: The Telegraph, 20 December 2023
  12. Content Article
    The prevalence of noncommunicable diseases (NCDs) or chronic diseases is increasing in Europe. NCDs now account for 90% of deaths in the WHO European Region, yet most health systems were developed to treat and care for people with acute conditions. Health care services are still lagging behind in terms of responding to the particular needs of those living with chronic conditions, including diabetes, cardiovascular disease (hypertension and heart failure) and respiratory diseases (asthma and chronic obstructive pulmonary disease).  Policy-makers and health-care managers are working to better organize health services to reflect and cater to the needs of these patients, for example by strengthening integrated primary health-care services. Important work is also needed to increase people’s knowledge, skills and confidence to manage their own conditions on a day-to-day basis, outside of health-care settings. Patients spend on average 2 hours per year with their health professional and the rest of the time they need to take care of their health themselves. Supporting patients to self-manage their condition is crucial to improving outcomes and reducing anxiety and complications.  WHO Regional Office for Europe has published a new “how-to” guide for policy-makers, health professionals, and education and training bodies on therapeutic patient education (TPE). The guide covers commissioning, designing and delivering TPE services and training programmes for health professionals. It also looks at the evidence and theory underpinning patient education, outlines key components for delivering a high-quality service and identifies implementation opportunities and barriers. 
  13. Content Article
    In a video and article published in Trends in Urology and Men's Health, Peter Duffy shares his experience of what it is to be a whistle-blower in the NHS, in the context of historical scandals of UK healthcare and whistleblowing, examining the roles of the NHS itself, the regulators and the law in the ensuing events.
  14. Content Article
    The Health Services Safety Investigations Body (HSSIB) Senior Safety Investigator, Helen Jones, blogs about some of the key benefits and risks of electronic patient record (EPR) systems used in healthcare, sharing what we are learning from our safety investigations.
  15. News Article
    Scientists have drawn a link between the Oxford-AstraZeneca vaccine and a “spike” in cases of a rare disease that can leave its victims paralysed. Three separate studies reported an increase in Guillain-Barré syndrome (GBS) shortly after the roll out of the AstraZeneca vaccine. GBS is a potentially deadly condition in which a person’s immune system attacks their nerves and gradually paralyses victims from the feet upwards. While most patients recover, it can be life-threatening or permanently debilitating. Two of the studies looked at rates of GBS in England and said there was an increase in cases “attributable to” the AstraZeneca vaccine, or that there was a probable “causal link”. The Telegraph has spoken to several people who developed GBS after receiving the AstraZeneca vaccine, and have become severely disabled as a result. On Friday, one of the victims spoke of his “anger” that he had the AstraZeneca jab without knowing that it posed such a risk. Anthony Shingler said: “It feels like the side effects were either missed or ignored.” Read full story (paywalled) Source: The Telegraph, 8 December 2023 Related reading on the hub: Interview with Charlet Crichton, founder of UKCVFamily Adverse reactions to Covid-19 vaccination - are adverse reactions adequately understood and are patients affected provided for in your area?
  16. News Article
    More than half of a trust’s staff told the Care Quality Commission (CQC) they did not have confidence in its executive leadership, with just 16% saying they did, the regulator has reported. The CQC surveyed staff as part of its inspection of East Kent Hospitals University Foundation Trust. Eighty-four per cent either said they disagreed with the statement “I have confidence in the executive team”, or neither agreed nor disagreed. That leaves just 16% who said they did have confidence. Some said they felt “traumatised”, “devalued” or “damaged” by a recent restructuring programme at the trust, which has been grappling major care quality and performance problems for several years. The CQC also revealed in a report today that it issued a warning notice to the trust after inspections at its two main sites in July. They ordered immediate improvements in its emergency departments, medical care and children and young people’s services. Read full story (paywalled) Source: HSJ, 20 December 2023
  17. Content Article
    The Right Honourable Sir Anthony Hooper was asked by the General Medical Council (GMC) on 5 September 2014 to conduct an independent review of how the GMC engage with individuals who regard themselves as whistleblowers. Here is the GMC's action plan to address the recommendations in the Anthony Hooper’s review.
  18. Content Article
    Research funded by the NIHR has found that air cleaning technologies designed to make social interactions safer in indoor spaces are not effective. The research was funded by the NIHR Health Protection Research Unit (HPRU) in Emergency Preparedness and Response. The researchers looked at technologies including: air filtration germicidal lights ionisers. They studied evidence about whether the technologies reduce the risk of catching airborne respiratory or gastrointestinal infections. The researchers found the technologies do not stop the spread of infections in buildings.
  19. Content Article
    In a study published in Rheumatology, researchers used the example of neuropsychiatric lupus, an incurable autoimmune disease that is particularly challenging to diagnose, to examine the different value given by clinicians to 13 different types of evidence used in diagnoses. This included evidence such as brain scans, patient views, and the observations of family and friends.
  20. News Article
    Mothers in England will be asked in detail if pregnancy or giving birth has affected their mental health as a result of new NHS guidance to GPs. The move is part of a drive by NHS England to improve support for women suffering postnatal depression or other mental health problems linked to their pregnancy or childbirth. Under the new guidance GPs will ask women more questions than before about how they are feeling when they attend their postnatal health check six to eight weeks after giving birth. Family doctors will look for any sign that the woman may have a condition such as postnatal PTSD as a result of experiencing a traumatic birth or psychosis induced by bearing a child. Anyone who the GP feels needs help with their mental wellbeing will be referred to specialist maternal mental health services, which have been expanded in recent years. Read full story Source: The Guardian, 18 December 2023
  21. Content Article
    NHS-funded dental services in England are in near-terminal decline: nearly six million fewer courses of NHS dental treatment were provided last year than in the pre-pandemic year; funding in 2021/22 was over £500m lower in real terms than in 2014/15; and there are widespread problems in accessing a dentist. So what is to be done? This major new policy briefing from the Nuffield Trust proposes a series of short-term actions relating to appointment recall intervals, commissioning and the workforce. It also sets out two approaches for longer-term action, which involve improving the current dental model or adjusting the NHS offer.
  22. News Article
    The traditional model of NHS dentistry is gone for good, experts are warning. The Nuffield Trust think tank said the service had been cut back so much it was now at the most perilous position in its 75-year history in England. It said restoring services would probably need an unrealistic amount of money and called for radical reform, suggesting NHS support may need to be completely scaled back for some adults. The Nuffield Trust said funding for NHS dentistry had suffered huge cuts in recent years. Some £3.1bn was spent in 2021-22 - a drop of £525m since 2014-15 once inflation is taken into account. It said the number of treatments being done each year was now six million lower than it was before the pandemic. The Nuffield Trust said tough policy choices needed to be made, suggesting one option could be to start charging adults for the full cost of treatment beyond emergency work and check-ups. Shawn Charlwood, chairman of the British Dental Association's general dental practice committee, said the report "reads like the last rites for NHS dentistry" and that "patients and this profession deserve some honesty here". He added: "The government say NHS dentistry should be accessible for all who need it. "The plain facts are we're not seeing any evidence of the reforms or the resources to realise that ambition." Read full story Source: BBC News, 19 December 2023
  23. Content Article
    On 11 January 2021 an investigation into the death of Susan Ann Gladstone was started. The investigation concluded at the end of the inquest on 20 November 2023. The conclusion of the inquest was Susan died as a result of a generally unknown interaction between warfarin and tramadol which caused exceptional thinning of her blood: 1a Intraparenchymal and subarachnoid haemorrhage.
  24. News Article
    NHS England has been told it must take action to raise awareness about the potentially fatal interaction between tramadol and warfarin, following the death of a patient. Graham Danbury, assistant coroner for Hertfordshire, issued a prevention of future deaths report on 1 December 2023, after Susan Gladstone, from Hertfordshire, died on 8 January 2021 from a bleed in the brain. An inquest, which ended on 20 November 2023, concluded that Gladstone “died as a result of a generally unknown interaction between warfarin and tramadol, which caused exceptional thinning of her blood”. Gladstone was prescribed tramadol twice for lower back pain: on 20 December 2020 and 4 January 2021. According to the report, she had been taking the anticoagulation medication warfarin for “a number of years”. The report continues: “There was nothing to warn the prescribing doctor of any possible interaction. I found on the balance of probabilities that an interaction between tramadol and warfarin had caused this dangerous, and in the event, fatal INR to develop. “In my opinion, actions should be taken to prevent future deaths and I believe you, NHS England, have the power to take such action.” Read full story Source: Pharmaceutical Journal, 13 December 2023
  25. Content Article
    A lack of coordination between the everyday primary and community services relied on by people using the NHS is leading to sub-standard care, missed opportunities for home or community-based treatments, and undue strain on hospitals that are already overstretched. There must be significant reform in terms of better staff training, improved data-sharing, flexible healthcare structures and collaboration across different professions in the healthcare system. These reforms will realise the potential of an integrated NHS and deliver more efficient healthcare services ensuring value for money and satisfied, healthier patients. This is the major conclusion of the report 'Patients at the centre: integrating primary and community care'. This report highlights the need for a seamlessly integrated patient-centric healthcare sector where patients are given the type of care they need, when, where, and how they need it; whether that be access to a GP, a pharmacist or a district or mental health nurse. The Government should focus more on preventative rather than reactive care to tackle the needs of an ageing population, many of whom are coping with complex health issues requiring intricate and continuous care.
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