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
    Living with seizures and crippling pain, Zara Corbett says she's "begging for help" as she copes with endometriosis. The 21-year-old told BBC News NI that if she had any other condition she would be receiving help. "With gynae problems, particularly endometriosis, you are left waiting for years." "Women should not be left suffering this pain, it's not good enough," the beautician said. Zara has been put into early menopause - which is one potential treatment for endometriosis. The County Down woman said Northern Ireland needed a dedicated centre to provide specialist support. "I am begging for help from medical professionals including support from a multi-agency network because we are at our wits end - life cannot go on like this," she said. Endometriosis UK, an organisation that helps women with the condition, said it was shocked and saddened that it does not see "good, prompt care" in Northern Ireland. Its chief executive, Emma Cox, who visited Belfast in May, said services in Northern Ireland were "lagging behind" the rest of the UK. "We hear of the very long waiting lists to access gynaecologists to get a diagnosis but also waiting lists to access surgeons, it's about the disease being taken seriously," Ms Cox said. Read full story Source: BBC News, 6 December 2023
  2. News Article
    There will be no national mandate for GPs to use advice and guidance in a certain number of cases, NHS England has told Pulse. National medical directors for primary and secondary care said that formalised pathways should be developed ‘locally’, and decisions should be based on an area’s population. In September, it was reported that NHS England’s upcoming outpatients strategy would further increase the use of advice and guidance (A&G) before GP referrals are accepted, with the RCGP then "voicing concerns" about this proposal. However, when asked about the reports that this would be mandated, Dr Stella Vig, national medical director for secondary care and clinical director for elective care, said she ‘doesn’t know’ where that came from, and ‘doesn’t recognise’ those comments. NHS England also released guidance clarifying the medico-legal risks and clinical responsibility for clinicians using A&G or referral assessment services (RAS), which is now available on the NHS Futures website. The guidance said that these forms of specialist advice are "expanding rapidly" as a result of improvements to digital services. On legal issues, it said liability ‘will be determined on a case by case basis’ but that GPs could be liable if "all relevant clinical information is not provided" when sending an A&G request. But specialists at hospitals would be accountable if they send back advice to the GP which is ‘not clinically appropriate’ or if they ‘refuse to accept a patient’. On turnaround times, NHS England has said that ‘local variables will ultimately dictate the agreed response times’ for hospital teams dealing with A&G – but the guidance recommends that the response time "should not exceed 10 working days for routine requests". Read full story Source: Pulse, 30 November 2023
  3. Content Article
    There’s been much discussion in the press and on social media about the role of physician associates and anaesthetic associates. Who exactly are they, and how are they trained? The Department of Health and Social Care says that they’re “trained in the medical model”—but what does this actually mean? Helen Salisbury gives her thoughts in this BMJ opinion piece.
  4. Event
    This conference focuses on developing systems and processes for locally driven ward and unit accreditation for quality. These approaches can be used as a tool to encouraging ownership of continuous quality improvement at ward, unit or service level, reduce variation and increase staff pride and team working within their practise. Through practical case studies of organisations that have successfully introduced locally driven ward and unit accreditation systems the conference will provide practical guide to implementing systems, and improving staff engagement in driving forwards improvement for the benefit of patients, service users and communities. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/ward-accreditation-for-quality-conference or email kerry@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow this conference on Twitter @HCUK_Clare #wardaccreditation
  5. Event
    ISO 45003:2021(E) is a guidance document that provides practical advice on managing psychosocial risks in the workplace. This document is designed to help organisations prevent work-related injury and ill health of their workers and other interested parties, and to promote well-being at work. This masterclass will explore the key concepts of ISO 45003:2021(E) and how they apply specifically to healthcare settings. It will discuss strategies for identifying and assessing psychosocial risks, implementing preventive measures, monitoring effectiveness, and promoting well-being in the workplace. The goal is for you to leave this masterclass with a comprehensive understanding of how ISO 45003:2021(E) can be used to manage psychosocial risks in your own organization. You will also have an opportunity to share best practices with colleagues from other healthcare organisations. Who should attend: Clinical staff, Managers, Admin staff, Policy makers and Board members. Key learning objectives: Participants will have a comprehensive understanding of psychosocial risks in the healthcare workplace. Participants will be able to identify preventive measures that can be implemented to manage these risks. Participants will understand the importance of monitoring and evaluating the effectiveness of these measures. Participants will have an increased awareness of their own well-being and safety in the workplace. Participants will have an opportunity to share best practices with colleagues from other healthcare organisations. Register
  6. Event
    Learn how the SIRO, CG and DPO should work together to ensure that organisational and technical measures are in place to protect the privacy of patient and service user data. Data Protection and Information Security measures and associated risk are considered risks mitigated where appropriate and reasonable. How legislation impacts on each of the roles. We will look at the roles and how they should work together and not in isolation. These 3 roles are referenced in the NHS Data Security & Protection Toolkit each having responsibility & accountability but there is synergy in the roles. These are important roles in assessing overall risks and issues of information sharing internally and externally. It will be beneficial for all three from an organisation to attend the course (although individual roles can attend) Register
  7. Event
    Learn how the SIRO, CG and DPO should work together to ensure that organisational and technical measures are in place to protect the privacy of patient and service user data. Data Protection and Information Security measures and associated risk are considered risks mitigated where appropriate and reasonable. How legislation impacts on each of the roles. We will look at the roles and how they should work together and not in isolation. These 3 roles are referenced in the NHS Data Security & Protection Toolkit each having responsibility & accountability but there is synergy in the roles. These are important roles in assessing overall risks and issues of information sharing internally and externally. It will be beneficial for all three from an organisation to attend the course (although individual roles can attend) Register
  8. Event
    This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. It pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. It advocates Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. This course supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  9. Event
    This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. It pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. It advocates Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. This course supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  10. Event
    The Department of Health and Social Care announced on the 5th April 2023 that the implementation of the Liberty Protection Safeguards will be delayed until at least the next general election (anticipated to be in Autumn 2024). With the delay to the Liberty Protection Safeguards it is more important than ever to ensure the existing scheme of Deprivation of Liberty Safeguards (DoLS) works, that providers understand the application of Deprivation of Liberty Safeguards and interaction with the Mental Capacity Act. It has been widely recognised that there are number of challenges associated with the current DoLS system, particularly in light of the increases in the number of DoLS applications – which have been seen across England and Wales. In light of the UK Government decision, we will need to consider how we strengthen the current DoLS system in order to continue to protect and promote the human rights of those people who lack mental capacity. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/virtual-online-courses/liberty-protection-safeguards-mca or email aman@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #LPS2024
  11. Event
    This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. There will be an extended focus on engaging and involving patients, families and staff following a death, and on learning from deaths including an update from a coroner. By 2024, all deaths in the community or acute settings that do not required to be referred to the coroner (non-coronial deaths) will need to be scrutinised by a medical examiner. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. The conference will also include a split stream where delegates can chose to focus on investigating and learning from either deaths in acute care, or deaths in primary and community care. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/virtual-online-courses/investigation-learning-deaths-hospital-mortality or email frida@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #LearningFromDeaths
  12. Event
    This National Virtual Summit focuses on the New PHSO National NHS Complaint Standards which are now being used and embedded into the NHS. Through national updates, practical case studies and in depth expert sessions the conference aims to improve the effectiveness of complaints handling within your service, and ensure that complaints are welcomed and lead to change and improvements in patient care. The conference will also reflect how involving people and their families in complaints and integrating the process with the new Patient Safety Incident Response Framework (PSIRF) to ensure patient safety actions and learning. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/virtual-online-courses/nhs-complaints-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #NHSComplaints
  13. Event
    This conference focuses on improving safety for hospice patients. The day will highlight best practice in improving safety in hospices, highlight new developments such as the implications of the new Patient Safety Incident Response Framework (PSIRF), and the new CQC Inspection Framework, and will focus on key clinical safety areas such as falls prevention, medication safety, reduction and management of pressure ulcers, nutrition and hydration, improving the response and investigation of incidents, preparing for onsite inspections and developing a compassionate culture in hospices. Register at https://www.healthcareconferencesuk.co.uk/virtual-online-courses/patient-safety-hospices or email aman@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow the conference on Twitter @HCUK_Clare #PSHospices
  14. Content Article
    Over the past two years, AHRQ has examined equity and its connections to agency activities in alignment with its mission to improve healthcare for all Americans. A new special issue of Health Services Research sponsored by AHRQ summarises the state of evidence and identifies opportunities to drive more equitable care.
  15. News Article
    The boss of a hospital trust being investigated by police for alleged negligence over 40 patient deaths has been accused of sending a hypocritical email urging staff to have the courage to raise concerns despite the dismissal of whistleblowing doctors. The investigation, Operation Bramber, was sparked by two consultants who lost their jobs after raising concerns about deaths and patient harm in the general surgery and neurosurgery departments of the Royal Sussex County hospital in Brighton. In an email to staff on Friday, the chief executive, George Findlay, said the trust was committed to learning from its mistakes. He said: “When things do go wrong, we must be open, learn and improve together. That openness is how we give people courage to raise concerns and make a positive difference to patient care.” James Akinwunmi, a consultant neurosurgeon who was unfairly dismissed by the trust in 2014 after he raised the alarm about patient safety, said Findlay’s email was “laughable”. He told the Guardian: “Whistleblowers, including myself, have done exactly what he is encouraging in the email and they were sacked for it, so you can draw your own conclusions. I suspect what they are doing is damage limitation. Instead, they should be dealing with surgeons who have been a problem for years.” Another more recent whistleblower, who did not want to be named, expressed incredulity at Findlay’s claim that he wanted to encourage staff to raise concerns. They said: “The email is hypocritical. How can staff have the ‘courage to raise concerns’ after what has happened to those who have? Those brave enough to blow the whistle about patient safety have been sanctioned, lost their job and had their lives destroyed.” Read full story Source: The Guardian, 3 December 2023
  16. News Article
    A health and social care minister privately said there was ‘systemic’ racism within the NHS and called for an investigation into it. Helen Whately told Matt Hancock of her belief in a private message which was today shown to the covid public inquiry. An inquiry hearing with Mr Hancock – who said he agreed with the point – was shown an exchange between Ms Whately, then care minister, and Mr Hancock in June 2020. The Guardian had reported the previous day that an internal report had found systemic racism at NHS Blood and Transplant. Ms Whately, who is now minister of state covering social care and urgent and emergency services, said: “I think the Bame next steps proposed are important but don’t go far enough. There’s systemic racism in some parts of the NHS, as seen in NHSBT.” She added: “Now could be a good moment to kick off a proper piece of work to investigate and tackle it.” Read full story (paywalled) Source: HSJ, 1 December 2023
  17. News Article
    A teaching trust has reported six ‘never events’ in less than two months, including incidents in a specialty already under review for errors. The incidents occurred at University Hospitals Birmingham between 26 July and 10 September, including two wrong-side lesion biopsies in dermatology, two incorrect blood transfusions, one injection to the incorrect eye, and one misplaced nasogastric tube. The two incorrect blood transfusions involved the same patient at Heartlands Hospital and were reported after a biomedical scientist carried out a retrospective investigation into the case. On both occasions, the patient was transfused with incorrect red blood cells. It brings the total number of blood transfusion events reported at UHB to seven since 2020-21. The issue is already subject to a review by the Royal College of Physicians after Mike Bewick identified concerns in his review of patient safety at the trust. It comes after clinicians working within the haematology specialty raised multiple concerns over patient safety in 2021 and intervention from the General Medical Council over concerns around junior doctors. John Atherton, chair of UHB’s clinical quality and safety committee, told the board a preliminary review into never events had identified that “maybe we weren’t addressing these [incidents] seriously enough”. Read full story (paywalled) Source: HSJ, 1 December 2023
  18. Content Article
    Large-scale improvement programmes are a frequent response to quality and safety problems in health systems globally, but have mixed impact. The extent to which they meet criteria for programme quality, particularly in relation to transparency of reporting and evaluation, is unclear. The aim of this study from Mary Dixon-Woods and colleagues was to identify large-scale improvement programmes focused on intrapartum care implemented in English National Health Service maternity services in the period 2010–2023, and to conduct a structured quality assessment. They found poor transparency of reporting and weak or absent evaluation undermine large-scale improvement programmes by limiting learning and accountability. This review indicates important targets for improving quality in large-scale programmes.
  19. Content Article
    In this episode of the King's Fund podcast, 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.
  20. News Article
    Ministers must intervene over systemic failures which are “too big for hospital or ambulance trusts to fix on their own” and have led to multiple preventable deaths, a senior coroner has warned. In a move usually considered rare for such an official, Cornwall and Isles of Scilly coroner Andrew Cox has written to the Department of Health and Social Care a second time over ongoing delays to ambulance responses and long ambulance handovers in the area. Last year he warned the NHS was “broken” after he ruled ambulance and emergency care delays contributed to the deaths of four people. Now, he has sent a similar report on the same types of failings in the deaths of John Seagrove, Pauline Humphris, and Patricia Steggles at Royal Cornwall Hospital to new health secretary Victoria Atkins. Mr Cox wrote: “I set out in my [prevention of future death report] last year my understanding of the reasons for the difficulties that are continuing in the Cornwall & Isles of Scilly coroner area. I do not believe those reasons will have changed significantly. ”The challenges are systemic in nature. They are too big for a single doctor, nurse or paramedic to fix. They are too big for either the hospital trust or the ambulance trust to fix on their own.” Read full story Source: HSJ, 1 December 2023
  21. News Article
    The government faces a rebellion with at least 30 Tories backing an amendment to extend interim payouts to more victims of the infected blood scandal. Up to 30,000 people were given contaminated blood products in the 1970s and 80s. Thousands have died. A Labour amendment will be brought on Monday calling for a new body to be set up to administer compensation. More than 100 MPs, including Tories Sir Robert Buckland, Sir Edward Leigh and David Davis, are backing the move. In a letter sent to Chancellor Jeremy Hunt, shadow chancellor Rachel Reeves called the scandal "one of the most appalling tragedies in our country's recent history." She added: "Blood infected with hepatitis C and HIV has stolen life, denied opportunities and harmed livelihoods." She praised Theresa May, who set up the Infected Blood Inquiry when she was prime minister in 2017. But she warned: "For the victims, time matters. It is estimated that every four days someone affected by infected blood dies." The chancellor, himself a former health secretary, told the inquiry in July that the government accepted the moral case for compensation. But he said no final decisions could be made before the inquiry publishes its findings - now expected in March next year. In August 2022, the government agreed to make the first interim compensation payments of £100,000 each to about 4,000 surviving victims and bereaved widows. But inquiry chairman Sir Brian Langstaff, said in April this year that the parents and children of victims should also receive compensation and also called for a full compensation scheme to be set up immediately. The Commons Speaker will decide on Monday which amendments to the bill MPs will vote on. But the government has said it will not be supporting the amendment. A Department of Health spokesperson said: "We are deeply sympathetic to the strength of feeling on this and understand the need for action. However, it would not be right to pre-empt the findings of the final report into infected blood." Read full story Source: BBC News, 3 December 2023
  22. News Article
    NHS “inaction” for more than a decade is causing unnecessary deaths of black, Asian and minority ethnic transplant patients, a report by MPs has concluded. An inquiry into organ donation in the UK found that minority ethnic and mixed heritage people faced a “double whammy of inequity”: they are more likely to need donors, because they are disproportionately affected by conditions such as sickle cell and kidney disease, and they are less likely to find the right blood, stem cell or organ match on donor registers. Matching tissue type is vital to the chances of successful treatment, and compatible donors who are not relations are more likely to be found among donors from a similar ethnic background. While there are more donors than in previous years, theall-party parliamentary group (APPG) for ethnicity transplantation and transfusion’s inquiry report says just 0.1% of blood donors, 0.5% of stem cell donors and less than 5% of organ donors are of minority ethnic or mixed background. As a result, white people are nearly twice as likely to find a stem cell donor and 20% more likely to find a kidney donor. The inquiry found a “staggering lack of consistent and detailed ethnicity data” within healthcare systems, which “undermines accountability and jeopardises the lives of those awaiting life-saving treatments”. Responding to the findings, Habib Naqvi, the chief executive of the NHS Race and Health Observatory, said such stark ethnic disparities in organ donor participation were of “grave concern” and required “more investment from health providers and targeted campaigns to raise awareness” to build trust in the healthcare system. Jabeer Butt, the chief executive of the Race Equality Foundation, said the inequalities were unacceptable. “Every person, regardless of ethnic background, deserves an equal chance at receiving life-saving transplants and donations when needed. This is a solvable problem, but it requires a shared commitment to action across government, health organisations and communities. Lives depend on it,” he said. Read full story Source: The Guardian, 4 December 2023
  23. Content Article
    Peter had a long history of depression, anxiety, and reported suicide attempts. He had acknowledged his reluctance to always engage fully with the treatment offered. On 3 August 2022 he was referred to the home treatment team for crisis intervention. After poor engagement he was transferred back to the community mental health team. On the 14 October he was detained by police under section 136 mental health act after expressing suicidal ideation. He told a psychiatric liaison service nurse he had no ongoing suicidal ideation and was referred to the community mental health team and his GP. He then contacted services further a number of times. On 10 November 2022 Peter was found deceased in his flat having taken a deliberate overdose of his prescribed medication. At the time of his death he was on the waiting list to be allocated a mental health care co-ordinator and there had been no multi-disciplinary meeting with all teams involved to agree how best to work with Peter. His cause of death was confirmed at post-mortem: 1a Carbamazepine toxicity. The conclusion reached was death was a consequence of suicide.
  24. Content Article
    On 22 November 2022, NHS England North West wrote to Greater Manchester Mental Health NHS FT (GMMH), to inform the trust it would be commissioning an Independent Review into the failings within the Trust’s services, reported at the Edenfield Centre, and the failure within the organisation to escalate concerns and mitigate against patient harm. This followed concerns raised by patients, their families, and staff, some of which were presented through the media. The intention is that the review’s work will bring some clarity and reassurance to patients, their families, and staff, as well as the broader public, in respect of the ongoing safety of services that the Trust delivers. NHS England has asked Professor Oliver Shanley OBE to lead the Independent Review, as the Independent Chair.
  25. News Article
    A hospital that unnecessarily delayed a man’s surgery at the last minute because he had HIV failed in their care, according to England’s Health Ombudsman. The 48-year-old from Walsall, who does not want to be named, had been due to have prostate surgery at Walsall Manor Hospital on 10 March 2020. His surgery was scheduled to be the first of the morning. As he was about to enter the operating room, he was told that due to his HIV status his surgery would now be moved to last on the operating list that afternoon. The hospital claimed that this was due to the level of cleaning and infection control that would need to take place following his surgery to reduce the risk to others. However, the Parliamentary and Health Service Ombudsman (PHSO), found that Walsall Healthcare NHS Trust acted inappropriately and failed the man. This is because the universal precautions that apply to all patients having surgery are enough to protect and prevent infections from spreading among patients and staff. Therefore, no additional cleaning should have been necessary. The policy of placing a patient at the end of an operating list usually relates to patients with a high-risk bacterial infection. It should not be applied to a person who has HIV and is receiving treatment. The Ombudsman also found that although the Trust had made some changes since this happened, they had not done enough to make sure the same mistake did not reoccur. PHSO recommended the Trust apologise to the man and create an action plan to stop this happening again. The Trust has complied with these recommendations. Read full story Source: Parliamentary and Health Service Ombudsman, 1 December 2023
×
×
  • Create New...