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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    A council is investigating after people ended up in hospital following Brazilian butt lift procedures. Brentwood Borough Council in Essex wants to hear from anyone in the area who has had the non-surgical work done. The procedure - also known as BBL or Liquid BBL - which uses a hyaluronic acid filler, is not illegal but is currently unregulated and can be fatal if not performed properly. The council said "an individual and associated companies" in Brentwood had been banned from carrying out BBL procedures until any risks had been "controlled". Environmental health officers were "investigating cases of hospitalisation due to members of the public undergoing a non-surgical aesthetic procedure, commonly known as a Brazilian Butt Lift, BBL or Liquid BBL in Brentwood," the council said. It is working with other local authorities and industry experts after a flurry of cases raised concern, including reports of treatment being carried out in hotel rooms. A spokesperson from Brentwood Borough Council said: "Individuals who have undergone these procedures have experienced excruciating pain, discomfort and infections, some of which have required medical interventions and hospitalisation." They urged anyone experiencing symptoms to "seek medical assistance immediately". Read full story Source: BBC News, 4 July 2024
  2. News Article
    Andrea Sutcliffe revealed in May that she would be resigning as chief executive and registrar of the Nursing and Midwifery Council (NMC) due to ill health. Marking the end of her tenure at the NMC, Ms Sutcliffe spoke to Nursing Times about some of her key achievements while leading the organisation over the last five years, and the challenges that lie ahead for her successor and the important work that must be prioritised in the coming months. Ms Sutcliffe’s departure comes at a tricky time for the regulator, which has come under fire for alleged failures in its regulatory processes and concerns about its internal culture. A series of articles were published by The Independent last year, which raised serious concerns about the inner workings of the NMC, the way it treats staff and how it handles whistleblowing. The newspaper reported that there was a “culture of fear” at the NMC that meant staff were afraid to speak out, while also claiming that there were issues of racial discrimination and sexism within the organisation. Ms Sutcliffe said the articles raised “really serious concerns” about the internal workings of the NMC and stressed the necessity of the independent reviews to “thoroughly scrutinise” what has been going wrong. “We’re trying to do things, but we’re clearly not doing enough and it’s not making the difference it needs to,” explained Ms Sutcliffe. “Some people’s experience within the organisation is not acceptable, and we’ve got to get that right.” Read full story (paywalled) Source: Nursing Times, 28 June 2024
  3. News Article
    The health minister has announced that a further review of clinical records of 18 patients who died under the care of neurologist Michael Watt is to be carried out. Mr Watt was at the centre of Northern Ireland's largest patient recall in 2018. In 2022 a review of 44 patients' records found significant failures in their care and treatment under Mr Watt and poor communication with the families. In a written statement to the assembly, Mike Nesbitt acknowledged "the exceptionally difficult circumstances which the families of deceased patients have experienced". It is anticipated that this phase of the Neurology Deceased Patients Review (DPR) will be completed before the end of March 2025. These reviews followed the 2018 recall of 2,500 outpatients who were in Dr Watt's care at the Belfast Health Trust. About one in five patients had to have their diagnoses changed. Mike Nesbitt said the work done to date as part of the Deceased Patients Review (DPR) has been "challenging and extensive". Read full story Source: BBC News, 3 July 2024
  4. News Article
    Higher Covid vaccination rates could help protect children against asthma attacks, according to research. While previous studies show that vaccination helps prevent Covid 19 illness, the authors believe this is the first study to assess whether Covid inoculation is associated with reductions in children’s asthma symptoms, by preventing viral illness in children with asthma. US researchers examined parent-reported asthma symptom prevalence in more than 150,000 children in the National Survey of Children’s Health between 2018-19 and 2020-21, broken down by US state. The data was then compared with the proportion of people aged five years and older who were vaccinated in 2020-21, as well as age-adjusted Covid mortality rates and any face mask requirements in enclosed spaces. With each increase of 10 percentage points in Covid vaccination coverage in US states, there was a 0.36 percentage point reduction in the rates of child asthma symptoms as reported by their parents, according to the study, published in Jama Network Open. Dr Andy Whittamore, the clinical lead at Asthma + Lung UK, said: “Two million children in the UK live with asthma. Infections such as Covid-19 and flu can cause irritation and inflammation in the airways of people with asthma. This can lead to an increase in mucus and narrowing of the airways, which in turn can cause symptoms such as breathlessness, wheeze, tightness in the chest and coughing and potentially trigger an asthma attack. “So it’s important for children with asthma to get any vaccinations they are eligible for, such as flu, to keep them safe. It’s also vital to make sure your child takes their preventer inhaler daily and always has their reliever inhaler with them.” Read full story Source: The Guardian, 3 July 2024
  5. Content Article
    Asthma was considered a risk for Covid-19 infection and hospitalisation early in the pandemic. Social distancing measures in 2020 were associated with lower rates of emergency visits and hospitalisations for asthma among children. Individual-level risk of Covid-19 infection was reduced with vaccination against SARS-CoV-2 for adults and children in 2020 and 2021, and several states sustained other infection prevention efforts (eg, face mask requirements) into 2021. Whether symptomatic asthma among children was associated with population-level Covid-19 illness exposure or mitigation strategies is not understood. The authors of this study hypothesised that symptomatic asthma would be positively associated with population-level Covid-19 overall mortality and would be inversely associated with population-level completion of the COVID-19 primary vaccination series and with state face mask mandates.
  6. News Article
    A hospital trust has ordered a review of potential death and harm caused by an outbreak of a serious healthcare-acquired infection, which is resistant to many antibiotics. Frimley Health Foundation Trust has seen outbreaks of carbapenemase-producing enterobacterales (CPE) at both its Frimley Park and Wexham Park sites, starting in the middle of last year, it has emerged. In total, it identified 94 new CPE cases in 2023–24 compared with just 20 in total in 2022–23. It is not clear what the outcomes were for patients infected with CPE, which is associated with a high mortality rate but often infects patients who are already seriously ill. The trust has commissioned a mortality and morbidity review but refused to answer any questions about it before publication. CPE bacteria are resistant to many antibiotics, including carbapenems, which are broad-spectrum drugs used to treat serious infections. CPE infections pose a particular risk to vulnerable patients and can spread rapidly in hospitals. There has been increasing concern about them in the UK, with reporting requirements increasing and screening and testing of patients stepping up. Read full story (paywalled) Source: HSJ, 4 July 2024
  7. News Article
    There’s a memory, or more specifically a moment, that came to define Heidi Metcalf’s second birth. It wasn’t saying goodbye to her husband and newborn before being wheeled into an operating theatre, or the heart attack she thought she was having as she lay there on the table. It was when a male obstetrician “ripped the placenta” out of her body, without word or warning. A nurse, Ms Metcalf knows the intervention - while immensely painful - was necessary. She couldn't push it out naturally, which was causing potentially fatal bleeding. But she hadn’t “seen or met this man before”, and she can’t get past the fact that her consent, during one of the most traumatic experiences of her life, “meant so little”. “It felt like a violation - I needed to feel involved in what was happening to my body, and not just like a bystander.” Ms Metcalf is one of thousands of Australian women who have come forward to tell their stories, after the federal government assembled a team of experts to tackle what it calls “medical misogyny”. So far, they have uncovered that a staggering two-thirds of females nationwide have encountered gender bias or discrimination in healthcare. And many say it is taking place when they're at their most vulnerable, such as during intimate examinations, or like Ms Metcalf, while in labour. Others report having their pain dismissed or dangerously misdiagnosed. Read full story Source: The Guardian, 2 July 2024
  8. News Article
    The NHS will face scrutiny over alleged failures to listen to whistleblowers’ warnings about baby killer Lucy Letby after the nurse was convicted of another attempted murder. Letby was convicted of trying to murder a “very premature” infant by dislodging her breathing tube in the early hours of 17 February 2016, following a retrial at Manchester Crown Court. The 34 year-old’s latest conviction comes after she was found guilty of the murders of seven babies and the attempted murders of six others at the Countess of Chester Hospital’s neo-natal unit between June 2015 and June 2016, following her original trial last August. The former nurse was given a rare whole-life order, making her one of Britain’s most prolific child serial killers. She is due to be sentenced for the further offence on Friday. Detective superintendent Simon Blackwell, who is strategic lead for Operation Hummingbird, said: “The investigation, which is ongoing, focuses on the indictment period of the charges for Lucy Letby, from June 2015 to June 2016, and is considering areas including senior leadership and decision making to determine whether any criminality has taken place. The investigation is complex and sensitive and specific updates regarding progress will be issued at the appropriate time. At this stage we are not investigating any individuals in relation to gross negligence manslaughter. “We recognise that this investigation has a significant impact on a number of different stakeholders including the families in this case and we want to reassure that we are committed to carrying out a thorough investigation. Since Letby’s original convictions in August 2023 it has been a very busy period for the investigation team. This has included a subsequent appeal, the re-trial for one count of attempted murder and the launch of the statutory public inquiry that Cheshire Constabulary is assisting with.” Read full story Source: The Independent, 2 July 2024
  9. News Article
    Almost half of nursing students in England have considered quitting before they graduate amid the worst workforce crisis in NHS history, according to the largest survey of its kind. Applicant numbers have fallen significantly since the end of a grant to support nursing students in 2017. Now a report by the Royal College of Nursing (RCN), seen by the Guardian, suggests that as many as 46% of those enrolled – about 32,000 students – could walk away. The cost of living was the top reason for students considering an early exit, with seven in 10 (70%) citing “financial difficulties” as a factor. Nursing students have to pay university fees of more than £9,000 a year. “I wasted so much time and put my sweat, blood and tears into something that is burning me out before I start and isn’t even paying enough. It makes me sad for myself that this is the profession I chose.” Nearly six in 10 respondents (58%) said witnessing low morale and burnout among qualified nurses had also prompted them to consider ditching their nursing degree. Read full story Source: The Guardian, 3 July 2024
  10. News Article
    The expansion and use of virtual ward beds has stalled so far in 2024 after strong growth in the second half of last year, according to analysis of official figures. The number of virtual ward “beds” occupied by patients increased by 38% between July and December 2023. But from the end of 2023 to May 2024, it has increased by less than 1%. The slowdown comes as ring-fenced national funding for virtual wards came to an end in March. The services – which involve the use of tech to care for patients in their own home when they would otherwise be in hospital – must now be drawn from wider urgent and emergency care funding. One integrated care board chief executive told HSJ the national virtual wards programme had become “peripheral” to wider challenges facing the health system, whereas it had previously been treated as a high priority on its own. Read full story (paywalled) Source: HSJ, 3 July 2024
  11. News Article
    The UK nursing regulator’s new interim chief executive has stepped down just four days into the job after facing widespread staff backlash over her links to a high-profile race discrimination case. Multiple staff working at the Nursing and Midwifery Council (NMC) raised concerns to its directors over the appointment of interim CEO Dawn Broderick, who was head of HR at another trust when it was found to have discriminated against a Black employee. The Independent can now reveal Ms Broderick resigned from the NMC on Monday evening. It is the latest in a succession of controversies to hit the nursing regulator, following reports uncovered by The Independent last year. These include allegations from whistleblowers that racism within the NMC was allowing complaints against nurses to go unchecked. Staff have come forward to The Independent, warning they do not have confidence the NMC’s board will take the issue of racism seriously. Read full story Source: The Independent, 2 July 2024
  12. Content Article
    High volumes of patients are transferred every day between health and care settings. Whilst efforts have have been made over several years to improve this process through the implementation of standards and the sharing of digital information, there is more to be done. Whole system improvements are required and significant further progress can be made to improve the quality and consistency of data shared between organisations. The Professional Standards Record Body (PRSB) has published a number of standards that support the transfer of care of patients between settings.  This toolkit concentrates on the PRSB eDischarge Summary Standard, which specifies the data to be shared between secondary and primary care to support the discharge of a patient from hospitals across the UK. This toolkit does not propose a one-size-fits-all approach and recognises that health and care services are organised in different ways across the UK.
  13. News Article
    The agonising pains came midway through Dr Rageshri Dhairyawan’s third cycle of IVF, ten years ago. “I felt as if a heavy metal shovel was scraping away at the lining of my abdomen,” she recalls. “It was like nothing I’d ever felt before,” she says. Her fear was ovarian torsion — “when the ovaries become so big from all the follicle stimulation that they twist on their stalk, which is excruciating and needs to be repaired surgically because the ovary becomes starved of oxygen.” Her husband rushed her to A&E where she was given morphine, then admitted to a gynaecology ward. As a scan revealed no ovarian torsion, “It was thought the hormones had flared up my endometriosis.” Dhairyawan was in so much pain she couldn’t move, and yet she recalls being treated as though she was an attention-seeker “trying to get strong opioids through dishonest means” and “as a nuisance for pressing my buzzer”. It was as if, she says, “I didn’t have something they thought was very serious so why was I still there? I just remember not wanting to feel like more of a nuisance because I knew what being a nuisance on a ward can look like — I’d been a doctor for ten years.” Dhairyawan’s husband demanded pain relief for her. She left hospital shaken. “It massively changed me,” she says. “The experience of not being listened to as a patient, not being taken seriously — it really shocked me. Because I thought, I’m a senior doctor, I know exactly how the NHS works, I know my medical condition, I now what to ask for. And I still can’t speak up and advocate for myself.” Read full story (paywalled) Source: The Times, 2 July 2024
  14. News Article
    NHS trusts are signing up to deliver efficiency savings of up to 9% of costs, HSJ has found. The Queen Elizabeth Hospital King’s Lynn has a cost improvement programme of nearly £30m in 2024-25, equivalent to 9% of spending, which is three times higher than the amount it delivered last year. Trusts and commissioners were last month issued with new financial targets as NHS England attempted to bring down a £3bn forecast deficit for local organisations. A spokeswoman told HSJ the trust had already identified three-quarters of the £30m, and said “we believe that there are further efficiencies in our system, which would see us go further than the 3.1% achieved last year.” She added: “All cost-saving initiatives go through a robust process to make sure that they will not impact patient safety or clinical care provided by the trust.” Read full story (paywalled) Source: HSJ, 1 July 2024
  15. Content Article
    The Independent Healthcare Providers Network (IHPN) have launched a toolkit to support independent healthcare providers to further improve multi-disciplinary team (MDT) working in the sector.  MDT working is an established practice in many areas of healthcare, including in the independent sector, and for patients with complex care needs such as cancer, MDTs are viewed as the gold standard for care. 
  16. Content Article
    East Lancashire Hospitals NHS Foundation Trust share their guide on human factors. It describes what human factors is and why it is so important alongside example case studies of how human factors is being used within the Trust.
  17. News Article
    Doctors are warning the UK medical regulator that wider use of physician associates in the NHS may risk patient safety and lead to greater inequalities in care in deprived areas that struggle to recruit GPs. The government’s plan to recruit 10,000 physician associates – healthcare professionals supervised by doctors – has angered many clinicians who consider the roles ill-defined and a potential threat to patient safety. The General Medical Council (GMC) is to regulate physician and anaesthesia associates, who also work under doctors’ supervision, from December. The doctors’ union, the British Medical Association, last week announced it was seeking a judicial review of the GMC over the “dangerous blurring of lines” between doctors and medical associate professions. It argues physician and anaesthesia associates need regulating, but not by the GMC. Other professional membership organisations want clarification of associates’ roles. The Royal College of General Practitioners (RCGP) told the GMC that regulation is a “significant step forward”, but the scope of practice needs to be urgently developed. Read full story The Guardian, 30 June 2024
  18. News Article
    The latest release of data from the Royal College of Nursing's Last Shift Survey shows the urgent need for investment in the nursing workforce and safety-critical nurse-to-patient ratios enshrined in law. New analysis finds more than 11,000 members reveals just a third of shifts had enough registered nurses. Chronic staff shortages mean individual nurses are often caring for 10, 12, 15 or more patients at a time. The RCN are now calling for safety-critical limits on the maximum number of patients a single nurse can be responsible for. Our survey found that 1 in 3 hospital shifts were missing at least a quarter of the registered nurses they needed. In A&E settings, significant numbers of nurses reported having more than 51 patients to care for. Across all settings, 80% of respondents said there aren't sufficient nurses to meet the needs of patients safely. RCN Acting General Secretary and Chief Executive Professor Nicola Ranger said: “Without safety-critical limits on the maximum number of patients they can care for, nurses are being made responsible for dozens at a time, often with complex needs. It is dangerous to patients and demoralising for nursing staff. “When patients can’t access safe care in the community, conditions worsen, and they end up in hospital where workforce shortages are just as severe. This vicious cycle fails staff and patients – it can’t go on. “We desperately need urgent investment in the nursing workforce but also to see safety-critical nurse-to-patient ratios enshrined in law. That is how we improve care and stop patients coming to harm.” Read full story Source: RCN, 1 July 2024
  19. Content Article
    The Patient Safety Movement Foundation offers a unique educational opportunity for healthcare professionals around the world to expand their knowledge in the theory and practice of patient safety. Building on the World Health Organization Global Patient Safety Action Plan, the fellowship aims to develop future leaders particularly from lower middle and middle income countries. The programme combines a year-long curriculum developed by patient safety experts in a variety of areas, taught via monthly live virtual classroom sessions. Fellows complete monthly readings on specific topics, actively participate in discussions on the interpretation of theory and methods, and its implication to practice. Fellows submit monthly reflections on their learning as well as a longer reflection at the end of the fellowship. Applied learning is achieved by completing a hands-on improvement project that explores and advances issues of patient safety in each fellow’s respective professional environment. Fellows are encouraged to publish the outcome of their project and present at conferences. Fellows are driven by a deep passion for patient safety, often sparked by first-hand encounters with patient harm events, and a desire to improve care outcomes in their home communities and workplace settings. They become part of a global social movement for patient and healthcare worker safety. Information on how to apply can be found in the link below.
  20. News Article
    Hackers behind a London hospital attack recently published records that include personal information about pregnant women, newborns, cancer patients, people suffering from schizophrenia and thousands of others across the UK and Ireland, revealing the breach was far more widespread than authorities have previously indicated. An analysis of the data trove by Bloomberg News found that it contains tens of thousands of medical records on patients from more than 400 public and private hospitals and clinics. Among the records are some 40,000 highly sensitive documents sent by doctors requesting biopsies and blood tests for individual patients in all regions of the UK and some hospitals in Ireland. A breach of the kind faced by Synnovis was inevitable, according to Saif Abed, a former NHS doctor and expert in cybersecurity and public health. “The NHS has some of best patient safety and cybersecurity standards in the world,” Abed said. “They are just immensely poorly enforced.” Abed said that there was a lack of mandatory cybersecurity audits on any contractors providing services to the NHS, which meant those contractors could have substandard cybersecurity practices that could in turn leave the NHS vulnerable. Read full story Source: Bloomberg UK, 26 June 2024
  21. Content Article
    Read the latest case studies from the National Guardian’s Office.
  22. Content Article
    In the dynamic landscape of healthcare, the unexpected deterioration of a hospital patient presents formidable challenges for medical professionals and families alike. It is during these critical moments that the concept of patient rescue becomes profoundly significant. Families, empowered with knowledge and effective communication strategies, play a pivotal role alongside healthcare providers in advocating for their loved ones and contributing to the success of rescue efforts. Watch this video from the World Patients Alliance to enhance your skills and confidence in advocating for patients' needs.
  23. Event
    The Welsh Government, in partnership with the Restraint Reduction Network and Improvement Cymru, is pleased to announce this lunchtime webinar launching a brand-new coproduced animation and additional resources to support our work to reduce restrictive practices in Wales. In this webinar, co-chaired by Joe Powell, CEO of All Wales People First and Zara Newman, Welsh Government Head of Safeguarding and Advocacy, you will learn more about restrictive practices, the Welsh Government’s Reducing Restrictive Practices Framework and the resources available to support practitioners across health, care and educational settings. The resources, including the new animation, have been developed by the Welsh Government to raise awareness of restrictive practices and their lawful use in care and educational settings. There will be opportunity to ask questions on the day. The webinar is open to all. Please note that this webinar will also be translated into Welsh in real time. Register
  24. Event
    The RRN is currently developing version two of the RRN Training Standards. Over several months they have been hosting a number of events to hear from colleagues across sectors and nations to help inform the development of version 2 of the Standards. The next webinar will provide an update on progress to version 2 of the RRN Training Standards. Hosted by RRN Trustee Salli Midgley and RRN Training Standards authors Sarah Leitch and Dave Atkinson, the webinar will provide an update on progress and provide opportunity for discussion around some key issues. Colleagues from the health, social care and education sectors, and from across the UK and Ireland, are welcome. We warmly welcome people with lived experience. The Restraint Reduction Network is a movement of people who want to eliminate the use of unnecessary restrictive practices, protect human rights and make a positive difference in people's lives. You can join the movement for free today at: https://restraintreductionnetwork.org/become-a-member/ Register
  25. Content Article
    Clive Flashman, Patient Safety Learning's Chief Digital Officer, presented at a Health Tech Alliance meeting to innovators on how to engage with patients to improve the safety of digital health innovation. Clive addressed the challenges in patient engagement such as accessibility, interoperability, safety standards and privacy and data use. The presentation slides from the meeting can be downloaded from the attachment below.
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