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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    In this study, Westbrooke et al. identified individual and organisational factors associated with the prevalence, type and impact of unprofessional behaviours among hospital employees. The study found that unprofessional behaviour is common among hospital workers. Tolerance for low level poor behaviour may be an enabler for more serious misbehaviour that endangers staff wellbeing and patient safety. Training staff about speaking up is required, together with organisational processes for effectively eliminating unprofessional behaviour.
  2. News Article
    NHS England has issued a national alert to all trusts providing maternity services after faults were discovered in IT software that could pose “potential serious risks to patient safety”. According to the alert, the Euroking electronic patient record provided by Magentus Software could be displaying incorrect patient information to clinicians. The Euroking EPR is used in the maternity departments of at least 15 trusts according to information held by HSJ. These organisations have been asked to “consider if Euroking meets their maternity service’s needs” and to “ensure their local configuration is safe”. Trusts with different maternity EPR providers have also been asked to reassess the clinical safety of their solutions. The potential “serious risks” relate to a fault in the Euroking EPR which allows new patient information to overwrite previously recorded information, which could lead to “incorrect management of the pregnancy and subsequent harm”. Read full story (paywalled) Source: HSJ, 8 December 2023
  3. Content Article
    The second annual Safety For All conference was held at the Royal College of Physicians in London on Tuesday 5th December 2023. Over 100 members of the healthcare community attended this event, including occupational health professionals, patient safety experts, frontline staff, patients and academics. The conference was hosted by the Safer Healthcare and Biosafety Network and Patient Safety Learning as part of the Safety For All campaign, supported by B. Braun, BD, Boston Scientific and Stryker. Attendees had the opportunity to hear from two keynote speakers: Lynn Woolsey, UK Deputy Chief Nurse at the Royal College of Nursing and Dr Henrietta Hughes, Patient Safety Commissioner for England. The conference was chaired and facilitated by Dr Rob Galloway, A&E Consultant at Brighton and Sussex Hospital NHS Trust, with a welcome introduction from Dr Ian Bullock, CEO of the Royal College of Physicians. There were a number of panel sessions and presentations throughout the day which are summarised in the attachment below, including on sustainability, antimicrobial resistance and antibiotic underdosing, violence at work, clinical communications, human factors, implementing the Patient Safety Incident Response Framework (PSIRF), and women's health and the menopause.
  4. Content Article
    The health service is facing workforce shortages and growing backlogs of care, as well as future increases in demand. In response, policymakers and providers are looking to advances in health technologies and data to improve quality and efficiency and reshape services to better meet future needs – most recently with the announcement of £100m to advance the use of artificial intelligence in health care. Ensuring new uses of health technologies or data have the backing of the public is critical if these are to become business as usual. As seen with the care.data scheme and the General Practice Data for Planning and Research programme, lack of public support can significantly constrain innovation and service transformation. So how does the UK public feel about the use of health technologies and health data? To explore this further, in March 2023 the Health Foundation commissioned a nationally representative public survey to investigate attitudes towards health technology and data uses and the key factors affecting these views.
  5. Content Article
    National Voices is committed to tackling racial inequalities – in healthcare, health status, within their own organisations and across the charity sector. With unacceptable statistics, like Black women are four times more likely to die around pregnancy than White women, and Black babies are almost three times more likely to die than White babies – still now, in 2023 – the need for effective action could not be stronger.  
  6. News Article
    GPs have warned that the extent of verbal abuse directed at them and their practice staff ‘is increasing’, with the majority reporting that things are worse now than during the height of the Covid pandemic. A UK-wide survey of more than 2,000 doctors – of which 617 were GPs – found that 85% of GPs have reported receiving verbal abuse from patients within the last 12 months. The research conducted by Medical and Dental Defence Union of Scotland (MDDUS) also found that 15% of GPs reporting verbal abuse said they ‘had to resort to involving the police’ to deal with abusive patient situations over the past year. In the survey, GPs identified key triggers such as ‘lack of access to a face-to-face consultation’ and ‘complaints about their quality of care’ as the factors that could escalate to verbal abuse. One GP who responded to the survey said: "During a consultation with a young adult, they got very irate and demanded I just give them what they came for. "I explained they had to calm down and we would only proceed then at which they called me an ugly, fat, c**t and threatened to smash my face in. That consultation stayed with me for quite a while after that." Another said: ‘A patient smashed the surgery front door (it needed replacing) because he didn’t get what he wanted when he wanted it. "This was very scary for staff and other patients and the police didn’t even come until the next day. I felt alone, defensive and wondered why we bother to try to provide a service when some patients have already decided it isn’t good enough for them." Read full story Source: Pulse, 7 December 2023
  7. News Article
    A hospital has introduced a new artificial intelligence system to help doctors treat stroke patients. The RapidAI software was recently used for the first time at Hereford County Hospital. It analyses patients' brain images to help decide whether they need an operation or drugs to remove a blood clot. Wye Valley NHS Trust, which runs the hospital, is the first in the West Midlands to roll out the software. Jenny Vernel, senior radiographer at the trust, said: “AI will never replace the clinical expertise that our doctors and consultants have. "But harnessing this latest technology is allowing us to make very quick decisions based on the experiences of thousands of other stroke patients.” Radiographer Thomas Blackman told BBC Hereford and Worcester that it usually takes half an hour for the information to be communicated. He said the new AI-powered system now means it is "pinged" to the relevant teams' phones via an app in a matter of minutes. "It's improved the patient pathway a lot," he added. Read full story Source: BBC News, 7 December 2023
  8. News Article
    NHS leaders have issued a warning over surging flu cases as the number of patients in hospital with the bug soared by more than 50% in a week. An average of 234 people were in hospital with flu each day last week – up 53% on the previous seven days. Figures from NHS England also showed a rise in norovirus cases in hospitals last week with an average of 406 cases per day, up from 351 the previous week and a 28% rise from last year. The latest data comes after public health officials sent a warning over whooping cough levels, with 719 suspected cases reported between July and November, up from 217 last year. This week several NHS hospitals have sent out alerts to the public warning of “extremely busy” A&Es. Dr Tim Cooksley, former president of the Society for Acute Medicine, warned: “Pressures are being exacerbated by increasing rates of sickness among colleagues, as well as pressures on precious resources such as isolation areas and side rooms, adding to the strain on already overstretched services... “Undoubtedly we will see more older patients enduring prolonged degrading periods of corridor care and many people experiencing difficult symptoms whilst they sit on elective waiting lists. “Most hospitals are already experiencing chaotic and dangerous scenarios.” He added that there was “a lack of understanding of the gravity of the situation” from new health secretary Victoria Atkins. Read full story Source: The Independent, 7 December 2023
  9. Event
  10. Event
    The Motherhood Group is thrilled to announce that the 2nd annual Black Maternal Health Conference UK is back to bridge the gap between Community, Service providers and Industries. This interactive event convenes researchers, healthcare providers, industry leaders, policymakers and mothers to rebuild trust, address systemic racism in maternity care, and effectively engage the needs of Black women. Through panels, workshops + open dialogue, we'll spotlight gaps within current systems while providing nuance on paths ahead towards equitable, dignified, culturally competent care. With the timely theme "Closing the Gap: Achieving Health Equity for Black Mothers", we have reputable speakers sharing powerful perspectives. And most importantly, Black mothers will be centered, our lived expertise guiding the way. This conference provides an unmatched chance to listen, learn and connect authentically alongside the community to explore barriers, tackle unconscious bias in care, advocate for system reforms, and discuss practical steps all stakeholders must take to eliminate disparities whilst honouring Black mothers' basic human rights to health. Register
  11. Event
    This free webinar will be discussing what it means to ‘Do Quality Differently’, including proven practices that will help you drive improved performance and manage risk. Hear multiple case studies that illustrate examples of results that are possible from implementation of these practices. Learn about practical ‘how to’ guidance to help you either get started in integrating these practices or improve the likelihood they will be sustained if you have already started on a Human Performance journey. Who will this be of interest to? Anyone in any industry who has a need to manage operational risk and improve operational performance. Register
  12. Content Article
    Potential serious risks to patient safety have been identified with the use of Magentus Software Limited’s Euroking maternity information system. These concern specific data fields: certain new patient information, recorded during a patient contact, can overwrite ('back copy') information previously recorded in the patient’s pregnancy record. certain pregnancy-level data (information relevant only to a specific pregnancy event) can be saved at a patient level (where information relevant throughout a person's life is recorded), causing new information to overwrite (‘back copy’) previously recorded data across an entire patient record. certain recorded pregnancy-level data can pre-populate into new pregnancy records (‘forward copy’), which can mean clinicians will see incorrect patient information, and attempts to correct this can result in the issue described at (ii) above.
  13. Content Article
    Early recognition and treatment of sepsis are linked to improved patient outcomes. Machine learning-based early warning systems may reduce the time to recognition, but few systems have undergone clinical evaluation. In this prospective, multi-site cohort study, Adams et al. examined the association between patient outcomes and provider interaction with a deployed sepsis alert system called the Targeted Real-time Early Warning System (TREWS). The findings indicate that early warning systems have the potential to identify sepsis patients early and improve patient outcomes and that sepsis patients who would benefit the most from early treatment can be identified and prioritised at the time of the alert.
  14. News Article
    More than 40 million women a year experience lasting health issues after childbirth, a global review has found, prompting calls for greater recognition of common postnatal problems. The sweeping analysis of maternal health worldwide shows a very high burden of long-term conditions that last for months and even years after giving birth. One in three new mothers worldwide are affected. The findings emerged from a series published in the Lancet Global Health and eClinicalMedicine, backed by the UN’s Special Programme on Human Reproduction, the World Health Organization and the US Agency for International Development. Prof Pascale Allotey, the director of sexual and reproductive health and research at the WHO, said: “Many postpartum conditions cause considerable suffering in women’s daily life long after birth, both emotionally and physically, and yet they are largely underappreciated, underrecognised, and underreported. “Throughout their lives, and beyond motherhood, women need access to a range of services from healthcare providers who listen to their concerns and meet their needs – so they not only survive childbirth but can enjoy good health and quality of life.” Read full story Source: The Guardian, 6 December 2023
  15. News Article
    Pregnant women have been urged to get vaccinated following a spike in suspected whooping cough cases in England and Wales. Official figures show doctors reported some 716 suspected cases between July and November - up from 217 in the previous period last year. Whooping cough, or pertussis, is a bacterial infection of the lungs and breathing tubes that spreads easily and infected tens of thousands of people before vaccines were introduced. It is easily preventable, experts say, but can sometimes cause serious problems for babies and children. Dr Gayatri Amirthalingam, consultant epidemiologist at the UKHSA, said the rise in suspected cases of whooping cough was “expected” due to low immunity as a result of the Covid pandemic. Despite vaccinations being available in the UK the infection hasn’t gone away “completely” but immunisation can provide “life-long protection”. “Social distancing and lockdown measures imposed across the UK during the COVID-19 pandemic had a significant impact on the spread of infections, including whooping cough,” Dr Amirthalingam added. “As expected, we are now seeing cases of whooping cough increase again so it’s vital pregnant women ensure they get vaccinated to protect their baby.” Read full story Source: The Independent, 7 December 2023
  16. Content Article
    This World Health Organization (WHO) resource is for all health workers, as well as other professionals working in the field of infection prevention and control (IPC). It will help you carry out a situational analysis, track progress and understand how to make improvements to IPC at the national and facility levels, in accordance with validated WHO standards and implementation materials. All the WHO tools and resources are freely available for use by all.
  17. Content Article
    This investigation explores the patient safety risk of unintended retention of surgical swabs after surgery. Surgical swabs are sterile pieces of gauze which are used to absorb bodily fluids, such as blood, during a surgical procedure. The investigation will: explore the factors associated with unintentional retained surgical swab events identify alternative safety controls to reduce the likelihood of foreign objects being unintentionally retained. The interim report analyses the findings of 31 NHS trust serious incident reports.
  18. News Article
    Patient Safety Learning sets out its response to the announcement by the Department of Health and Social Care that it will be reviewing the statutory duty of candour for health and social care providers in England. "We welcome today's announcement by the Government that they will hold a review into the statutory duty of candour for health and social care providers. The statutory duty of candour is intended to ensure that healthcare providers are open and transparent with the public. It sets specific requirements for organisations to follow when things go wrong with care and treatment. Earlier this year the Parliamentary and Health Service Ombudsman highlighted concerns around the implementation of duty of candour and called for a review to assess its effectiveness in their report Broken trust: making patient safety more than just a promise. In our response to this report, we supported this recommendation. As part of reviewing problems with compliance, we believe that there are also broader questions that also need to be addressed concerning how the implementation of this is monitored and what remediation and redress is available to patients and the families when these obligations are not met. We also believe that this review should look at how the duty of candour is being implemented in light of the introduction of the new Patient Safety Incident Response Framework (PSIRF), given that this represents a significant change to the NHS’s approach to incident investigation." Source: Patient Safety Learning, 6 December 2023
  19. News Article
    Private hospitals saw record admissions this year after hundreds of thousands of people sought care through their insurance amid rocketing NHS waiting lists, new figures show. Between January and June 443,000 private treatments took place – a 7% rise from 2022, the vast majority of which were claimed through medical insurance policies. According to the Private Hospital Information Network (PHIN), which collects data from hospitals in the sector, there was a 12% increase in the number of people paying for care via insurance with 157,000 people using this route from January to March and 148,000 from April to June this year. The news comes as the NHS’s waiting list continues to grow with almost 7.8 million appointments recorded. Recently published data shows that there is a total of 6.5 million individual people on the waiting list. Read full story Source: The Independent, 7 December 2023
  20. News Article
    A coroner has warned a trust in the West Midlands for the third time about bed shortages, after three patient deaths which he believes are linked. In his report on the death in July of Philip Malone, area coroner for Birmingham and Solihull James Bennett told Birmingham and Solihull Mental Health Foundation Trust that its psychiatric bed capacity “remains inadequate”. Mr Malone – who was diagnosed with treatment-resistant schizophrenia in the 1980s and adult autism in May this year – died by suicide while awaiting an inpatient psychiatric bed at BSMHFT after a deterioration in his symptoms of anxiety, thought disorder, and hallucinations. Clinicians decided on 28 June that Mr Malone should be detained under the Mental Health Act, but as no inpatient psychiatric bed was available, he remained in the supported accommodation. Mr Malone died on 3 July. In a public report warning of the risks which may cause future deaths, issued last week, Mr Bennett said he had issued two previous “prevention of future death” reports which focused on a “chronic lack” of mental health resources in Birmingham and Solihull. Mr Bennett said: “The issue of adequately funding psychiatric beds is local and national. Locally, BSMHFT requires its commissioners to provide the necessary funding. “Whilst some action may have been taken it is insufficient to resolve the problem. It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken.” Read full story (paywalled) Source: HSJ, 5 November 2023
  21. Content Article
    Mr Malone was diagnosed with treatment resistant schizophrenia in 1983 and had been sectioned multiple times. In May 2023 he was diagnosed with adult autism. At a review on 31 May he was considered to be stable. On 15 June a routine clozapine review identified sub-therapeutic levels but this was not notified to his clinicians. Sub-therapeutic levels of clozapine are likely to have contributed to a worsening in his symptoms. Around 24 June he was noted to have suffered a significant deterioration – with symptoms of thought disorder, anxiety, and responding to hallucinations – and following a mental health act assessment on 28 June clinicians wanted to detain him under section 2. No inpatient psychiatric bed was available. Whilst he awaited a bed, he remained in the community with daily visits from the mental health team. Last contact was on 1 July when he accepted his medication and appeared more settled. There was no answer when he was visited on 2 July. His room at supported accommodation was entered on 3 July and he was found deceased. Recently he had expressed no suicidal ideation. Post-mortem examination confirmed the medical cause of death was:  1a Cervical spinal cord injury. 1b Laceration. The conclusion of the inquest was that death was the consequence of suicide.
  22. Content Article
    The latest Lancet Countdown report underscores the imperative for a health-centred response in a world facing irreversible harms.  Climate inaction is costing lives and livelihoods today, with new global projections revealing the grave and mounting threat to health of further delayed action on climate change. But bold climate action could offer a lifeline for health. This year’s report launches just weeks before the COP28 which has a health focus for the first time. The findings underscore the opportunity of a lifetime that COP could help deliver – through commitments and action to accelerate a just transition. Without profound and swift mitigation to tackle the root causes of climate change and to support adaptation efforts, the health of humanity is at grave risk.  Our 2023 Report tracks the relationship between health and climate change across five key domains and 47 indicators, providing the most up-to-date assessment of the links between health and climate change.
  23. Content Article
    Patient-initiated follow up (PIFU) is an appointment process that helps hospitals manage capacity and puts patients in control of making appointments, when they need them. In traditional care models, patients who have had treatment or surgery, or suffer with chronic conditions are provided with a set care plan and offered scheduled follow-up appointments either conducted in person, or remotely. PIFU offers an alternative way of organising planned follow-up care for patients following their elective procedures, rather than automatically being scheduled for appointments. This aims to give greater control to patients over the timing of their follow-up appointment based on their health status needs, helping patients save time, money and the inconvenience of travelling to pre-arranged appointments they may not need.
  24. Content Article
    The NHS’s deal with the US tech company Palantir raises privacy concerns, but a unified database could be a medical gamechanger writes Martha Gill in an article for the Observer. Governments have been trying to stitch together our patchwork system for decades. Billions have been lost in these attempts. However, they always run up against the same problem: people just don’t want to share their medical data, even when assured it will be anonymised. When the government aimed to build a collection of anonymous GP health records, around a million patients opted out. The latest of these attempts has closed a loophole: patients cannot now opt out. But this has enraged civil liberties groups, which are concerned about the company chosen to merge, clean and provide tools for sorting through the data.
  25. News Article
    A consultant gynaecologist who admitted sterilising a woman without her permission has been suspended from practising for 12 months. The woman - known as Patient A - was sterilised by Dr David Sim following an emergency caesarean section. Dr Sim previously admitted that the sterilisation was not necessary to save the woman's life or prevent harm to her health. The procedure took place at Daisy Hill Hospital in Newry in September 2021. On 1 December, the Medical Practitioners Tribunal Service (MPTS) found his fitness to practice was impaired. The tribunal previously heard Dr Sim and the patient had discussed sterilisation twice over a period of years, but the patient had never consented or expressed any wish to undergo sterilisation. When she required the emergency caesarean section, Dr Sim delivered the baby and blocked the patient's fallopian tubes to permanently impair their normal function. Dr Sim previously admitted to the tribunal that this was in violation of the woman's reproductive rights. Read full story Source: BBC News, 5 December 2023
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