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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Unconscious bias, which is deeply ingrained and often hard to recognise, impacts decisions in ways we may not realise. Implicit bias, shaped by repeated exposure to real-world interactions, also plays a significant role in this phenomenon. As such, in healthcare, intuitive decision-making can be a double-edged sword. It can help during emergencies but can also lead to discrimination and biases, especially in complex situations. In addition, hidden and automatic biases, which are further strengthened by unquestioned repeated practices, have a significant impact on daily healthcare interactions. Historically, gynaecology occupied a marginalised position within the realm of surgical care, often relegated to the status of a ‘Cinderella service’. This perception stemmed from societal attitudes and gender biases, which influenced how gynaecological surgeries were viewed in comparison with other surgical specialties. Gynaecology, being predominantly focused on women's reproductive health, was sometimes considered less prestigious or less prioritised than other surgical fields such as orthopaedic surgery or general surgery.
  2. Content Article
    A second victim is a healthcare worker who is traumatised by an unexpected adverse patient case, therapeutic mistake, or patient-associated injury that has not been anticipated. Often, the second victim experiences direct guilt for the harm caused to the patients. Healthcare organisations are often unaware of the emotional toll that adverse events can have on healthcare providers (HCPs) who can be harmed by the same incidents that harm their patients. This study aims to examine the second victim phenomenon among healthcare providers at Al-Ahsa hospitals, its prevalence, symptoms, associated factors, and support strategies.
  3. News Article
    The national clinical director for older people has announced he is leaving NHS England and said a major government funding settlement will be needed to maintain progress and take community services to the ‘next stage’. Adrian Hayter joined NHSE in 2019 as NCD for older people and integrated person centred care. Dr Hayter, who is also a longstanding GP partner in Berkshire, said community services were now much more prominent at NHSE — and in its asks of the service – than they were four years ago. He said: “When I first came in, there wasn’t very much in planning guidance about what was happening in the community at all. Now that is different and we are expecting a range of initiatives in 2024. “But the future is that all of these things are not individual programmes - they’re all part of a particular approach to how we manage and support people for as long as possible in their own homes. “Urgent community response [where services are required to respond within two-hours to urgent needs, referred from a range of services] and virtual wards are a continuum of care. “And the growth of virtual wards have helped extend what happens in the community all the way through to the acute level care.” National long-term funding for several of the new services – badged in the 2019 long-term plan as “Aging Well” – is also now due to end, with integrated care boards instead asked to commission them locally. Dr Hayter warned that, as well as moving those services closer together, there needed to be a future government spending review settlement aimed at growing community services, to meet the needs of the rapidly ageing population. Read full story (paywalled) Source: HSJ, 18 December 2023
  4. News Article
    Scientists are hoping a new 45-minute blood test can quickly identify sepsis before it kills. Sepsis is a life-threatening reaction to an infection. It occurs when the body overreacts and starts attacking its own tissues and organs. The hard-to-diagnose condition kills nearly 50,000 Brits a year more than breast, prostate and bowel cancer combined - with severe cases taking just hours to prove fatal. Dr Andrew Retter, an intensive care consultant at Guy’s and St Thomas’ NHS Foundation Trust, who is trialling the test told The Times: “If someone comes into A&E and they’re sick, we can spot that early and start treatment early. “For every hour antibiotics are delayed, people’s mortality goes up by about 7 or 8 per cent if they’ve got sepsis.” Melissa Mead’s one-year-old son William died after weeks of a lingering cough and concerns were dismissed by doctors and 111 operators. The campaigner told The Times: “A test like this at the point of care in A&E, for example, could remove the uncertainty about sepsis, which presents differently in different people. “This could give people a chance at life that my son never had.” Read full story Source: The Independent, 17 December 2023
  5. Content Article
    In the UK, surgical care is responsible for the equivalent of about 5.7 million tonnes of carbon dioxide emissions each year – equivalent to that from heat, electricity, transport and waste of 700,000 UK homes. Reducing the emissions produced during surgery would be a significant step towards the NHS achieving its aim to be net zero by 2045. The report shows that solutions are available and in many cases could result in better options for patients while at the same time costing the NHS less. Reducing and reusing products used in surgery, shutdown checklists for operating rooms to save energy when they are not in use, switching to less harmful anaesthetics, and surgeons and patients working together to optimise their treatment are all highlighted as ways in which carbon emissions could be reduced. This landmark report highlights a number of successful initiatives that have already been implemented. For example, a team at Imperial College Healthcare NHS Trust successfully reduced both carbon dioxide emissions and cost by switching from general to local anaesthesia for some procedures, and from disposable to reusable surgical gowns. The report, which involved collaboration across multiple organisations involved in different aspects of surgical care, was produced by the UK Health Alliance on Climate Change, Brighton and Sussex Medical School and the Centre for Sustainable Healthcare.
  6. Content Article
    Monica is a project manager for the South East London Local Maternity and Neonatal System. In this interview she talks about her work, including setting up the perinatal pelvic health service across south east London.
  7. Content Article
    This advocacy brief aims to raise awareness and calls for action to step up patient engagement in healthcare, in line with the objectives of World Patient Safety Day 2023. Its content was structured to follow the outline of the Global Patient Safety Action Plan 2021–2030, which defines and makes recommendations to stakeholder groups.
  8. Content Article
    In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on the charity’s work and some of the key patient safety developments in the past 12 months and looks ahead to 2024.
  9. News Article
    Health experts say more attention should be given to patients’ experiences after research found multiple examples of their insights being undervalued. A study led by the University of Cambridge and King’s College London found clinicians ranked patient self-assessments as the least important when making diagnostic decisions. Ethnicity and gender were felt to influence diagnosis, particularly a perception that women were more likely to be told their symptoms were psychosomatic. Male clinicians were more likely to say that patients overplay symptoms. The findings prompted calls for clinicians to move away from the “doctor knows best attitude” when caring for patients. One patient shared the feeling of being disbelieved as “degrading and dehumanising”, and added: “I’ll tell them my symptoms and they’ll tell me that symptom is wrong, or I can’t feel pain there, or in that way.” Read full story Source: The Guardian, 18 December 2023
  10. News Article
    The average wait for an autism diagnosis in England has hit 300 days, according to new NHS data. That is up 53% from 12 months prior and exceeds the NICE target of 91 days. The National Autistic Society described such wait times as appalling, warning "autistic people shouldn't miss out on vital support because they haven't got a timely assessment." A government spokesperson said it had made £4.2m available this year to improve services for autistic children. Rose Matthews, 63, from County Durham, said receiving an autism diagnosis had been "lifesaving - and I don't say that flippantly". Before receiving their diagnosis at the age of 59, Rose, who uses "they" and "them" as personal pronouns, said: "My life was unravelling. "My career was unravelling." They said their GP had "deeply misguided ideas about what being autistic meant" and brushed them aside. Joey Nettleton-Burrows, policy and public affairs manager for the National Autistic Society (NAS), said: "We do see lot of misunderstanding from people, and it can include health and social care staff, but I wouldn't say it is common with GPs." Read full story Source: BBC News, 15 December 2023
  11. News Article
    Urgent action is needed to address NHS computer failings which are causing harm to patients, the patient safety watchdog has told BBC News. The watchdog has evidence of patient deaths due to IT system errors. The government called the reports "concerning" and said it would work with NHS England to take necessary action to protect patients. A recent investigation found thousands of hospital letters were unsent due to computer issues. The Health Services Safety Investigations Body (HSSIB) says IT failures are among the most serious issues facing hospitals in England. "We have seen evidence of patient deaths as a result of IT systems not working," said interim head, Dr Rosie Benneyworth. Dr Benneyworth cited the example of a patient who was found unresponsive and then wrongly identified by healthcare staff as not wishing to be resuscitated. Staff were unable to access information on the patient quickly through their IT system, which would have shown a mistake had been made, said the watchdog. Read full story Source: BBC News, 16 December 2023
  12. Content Article
    This overview provides detail on the structure of NHS England’s executive group.
  13. Content Article
    This toolkit from the Institute from Healthcare Improvement (IHI) equips patient safety and finance leaders with tools and a collaborative approach to make a compelling business case for organizational investments to advance patient and workforce safety initiatives.
  14. Content Article
    What is the impact of the poor condition of equipment and buildings? In September, the Chief Financial Officer of NHS England, Julian Kelly, told the Public Accounts Committee that every day ‘hospitals are having to shut units and decant patients into other spaces’. St Peter’s Hospital in Essex, a former Victorian workhouse, has had to relocate some inpatient services to other hospitals this winter amid issues with a leaking roof, weak flooring and broken lifts. And Queen Elizabeth Hospital in King’s Lynn has more steel props to stop RAAC (reinforced autoclaved aerated concrete) collapsing in its buildings than it does hospital beds. Underinvestment impacts the delivery of care, causing disruption for patients, and adding to the burden on staff who have to negotiate working in dilapidated buildings on top of their workload.  
  15. Content Article
    This study compared two quality improvement (QI) interventions to improve antenatal magnesium sulphate (MgSO4) uptake in preterm births for the prevention of cerebral palsy. It found that PReCePT improved MgSO4 uptake in all maternity units. Enhanced support did not further improve uptake but may improve teamwork, and more accurately represented the time needed for implementation. Targeted enhanced support, sustainability of improvements and the possible indirect benefits of stronger teamwork associated with enhanced support should be explored further.
  16. News Article
    The NHS in England has a record repair bill of almost £12bn, new figures show, with ministers needing to find more than £2bn for urgent maintenance to prevent catastrophic failure. The annual report on the condition of the health service’s estate said on Thursday that the cost of improving rundown buildings and decrepit equipment was two and a half times larger than in 2011-2012, when it stood at £4.7bn. The cost of the “high-risk” backlog – situations where the need to repair or replace facilities and equipment must be urgently addressed to prevent serious failure, significant injury or major disruption to clinical services – rose by almost a third to a record £2.4bn. This was £0.3bn in 2011-2012. However, investment to reduce the backlog fell in the last year from £1.41bn to £1.38bn, a fraction of what is needed to restore the NHS estate back to acceptable levels of risk. The stark figures cover a time prior to the health service becoming embroiled in the crumbling concrete crisis which initially hit school buildings. Sir Julian Hartley, the chief executive of NHS Providers, said that “too many NHS buildings are quite simply falling to bits”, and that we need “a step change in the government’s approach to planning and funding essential capital investment in the NHS”. He said: “The eye-watering cost of trying to patch up creaking infrastructure and out-of-date facilities is mounting at an alarming rate. “Mental health, hospital, community and ambulance services are crying out for much-needed funding for critical projects to overhaul ageing estates and to give patients and staff the safe, reliable conditions they need." Read full story Source: The Guardian, 14 December 2023
  17. News Article
    Ambulance handover delays rose last week with close to 13,000 crews waiting more than an hour to offload patients — marginally more than the comparable week last year. Week of 27 November 2023 figures were missing data for several days from some trusts, NHSE said. The number of hour-plus waits for ambulancs to pass patients to emergency departments was 12,797, according to new NHS England data. That appeared to be steeply up from about 8,000 in the past two weeks, although NHSE said last week’s was not directly comparable due to missing data. It was just ahead of the 12,534 recorded for the week ending 11 December last year. Last year the numbers rose to over 16,000 in the third week in December then peaked at 18,720 in the week running up to New Year, in what many said was the worst winter crisis for decades, amid a sharp, early wave of flu. This year the numbers of long waits have risen earlier than last, and several ambulance trusts have reported coming under severe pressure in the last few days. NHS England has warned junior doctors strikes next week and in the new year may compound hospital flow problems. Read full story (paywalled) Source: HSJ, 15 December 2023
  18. Content Article
    Hearing and listening to patients is at the centre of patient safety. As healthcare services in England work to bring to reality the transformation sought in the NHS Patient Safety Strategy (July 2019), independent sector providers have the challenge of ensuring that they too provide an equal opportunity for private patients' voices to be heard. Taking complaints seriously, having robust processes and learning from them is integral to this, as ISCAS Director Sally Taber explains in her blog. 
  19. Content Article
    Since the launch of the national Perinatal Mortality Tool (PMRT) in early 2018, over 23,000 reviews have been started. This fifth annual report presents the findings for reviews completed from March 2022 to February 2023 coinciding with the third year of the global health emergency due to the COVID-19 virus.
  20. News Article
    An "evil" nurse who drugged patients on a stroke unit for an "easy shift" and a healthcare worker who conspired with her have been jailed. Catherine Hudson, 54, was found guilty of giving unprescribed sedatives to two patients at Blackpool Victoria Hospital in 2017 and 2018. She was also convicted of conspiring with Charlotte Wilmot, 48, to give a sedative to a third patient. Hudson was jailed for seven years and two months. Wilmot was sentenced to three years. Evidence during the trial highlighted the "dysfunctional" drugs regime on the stroke ward with free and easy access to controlled drugs and medication which led to "wholesale theft" by staff. Prosecutors described it as a "culture of abuse" after police examined WhatsApp phone messages between the co-defendants and other members of staff. The pair were investigated after a student nurse witnessed events while on a work placement on the stroke unit and told senior managers in November 2018, who called in police. The whistleblowing nurse, who the prosecution had asked not to be named, told officers she had concerns over the use of insomnia medication Zopiclone, which can be life-threatening if given inappropriately. She said Hudson had told her the patient had a Do Not Resuscitate Order in place "so she wouldn't be opened up if she died or... came to any harm". Read full story Source: BBC News, 14 December 2023
  21. News Article
    A trust is reviewing more than 100,000 patients on its outpatient lists, after concerns emerged that some had ‘been lost whilst on hold’ for follow-up appointments. A report from Buckinghamshire Healthcare Trust, leaked to HSJ, found 116,575 patient records without a scheduled follow-up after an outpatient consultation, with more than half of those left inappropriately without action, some dating back a decade. The review was triggered after staff spotted cases in which patients had been “lost whilst on hold”, the report said. The trust this week told HSJ that, since the initial discovery in the summer of last year, it had been validating the lists and reduced the number of outstanding records to 47,778. It aims to complete the reviews in the next two months. It told HSJ it had undertaken a harm review and found no “systemic harm”. Concerns have been raised over several years about the extent of overdue and unreviewed patients on follow-up lists, and the potential for them to deteriorate and come to harm. There are no national figures monitoring the patients, many of whom have long-term health needs. Read full story (paywalled) Source: HSJ, 15 December 2023
  22. News Article
    People who have been hospitalised with flu are at an increased risk of longer-term health problems, similar to those with long Covid, data suggests. While the symptoms associated with such “long flu” appear to be more focused on the lungs than ongoing Covid symptoms, in both cases the risk of death and disability was greater in the months after infection than in the first 30 days. “It is very clear that long flu is worse than the flu, and Long Covid is worse than Covid,” said Dr Ziyad Al-Aly, a clinical epidemiologist at Washington University in St Louis, Missouri, who led the research. He was motivated to study the phenomenon after observing the scale of long-term illness experienced by people who have recovered from Covid. “Five years ago, it wouldn’t have occurred to me to examine the possibility of a ‘long flu.’ But one of the major lessons we learned from this pandemic is that a virus we all initially thought could only cause acute disease is leaving millions of people with long Covid, he said. “We wondered whether this could be happening with other things. Could this be happening with the flu, for example?” The research, published in the Lancet Infectious Diseases, found that while Covid patients faced a greater risk of death or hospital readmission in the following 18 months, both infections carried a significant risk of ongoing disability and disease. Read full story Source: The Guardian, 14 December 2023
  23. Content Article
    Mesh slings made of the same polypropylene plastic as the suspended women’s slings have been implanted into nearly 200 men across the UK suffering incontinence after prostate cancer. The operations were part of a trial in 28 hospitals where half the slings failed to fix men’s urinary leakage. Worse, just like the majority of women’s mesh implant trials, the full range of mesh-related pain was not logged in any paperwork.
  24. Content Article
    A monthly journal for all operating theatre staff covering surgical and anaesthesia news.
  25. News Article
    Only half of staff across two acute trusts were fully trained in the use of a new electronic patient record before its introduction, which led to disruption and patient harm, HSJ has revealed. The implementation of Oracle Cerner’s EPR at Royal Surrey Foundation Trust and Ashford and St Peter’s Hospitals FT was carried out, despite the trusts not having achieved their target of 80% of staff having completed the necessary training, newly disclosed documents show. HSJ has also seen an internal report by the Royal Surrey’s informatics team which warned of risks to patient safety and data problems, unless preparations improved in the three months leading up to go-live. The two acute trusts implemented the EPR in May last year under a programme called Surrey Safe Care, but there have been multiple problems ever since – including some of the issues that the internal report warned of. The trusts acknowledged the process had been “challenging” but said they had trained a higher proportion of the staff who were working in the two weeks after go-live, with Royal Surrey describing the findings of the internal informatics report as an “inaccurate representation” of readiness. Read full story (paywalled) Source: HSJ, 13 December 2023
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