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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    NHS England has outlined plans to develop an improvement approach - NHS IMPACT - to support continuous improvement. There are also ambitions for integrated care systems (ICSs) to become ‘self-improving systems’. This report, written and researched by Sir Chris Ham and jointly commissioned by the NHS Confederation, the Health Foundation and the Q community, reviews the experience of a number of ICSs identified as being at the forefront of this work, focusing on the approaches they have taken and the results achieved.
  2. News Article
    Several trusts are failing to admit their sickest emergency patients in a timely fashion, despite performing well in official waiting time statistics, HSJ can reveal. The internal NHS England data, obtained via a Freedom of Information request, reveals 12 trusts which have performed above the average against the four-hour accident and emergency target are delivering relatively poor waiting times for patients who require admission, as opposed to those who, for example, can be discharged after being seen. The unpublished provisional data shows an average of just 30% of admitted patients in England spend four hours or less in A&E against the 95% target. But many trusts are falling significantly below this – including those trusts at or around NHSE’s interim target of 76% for four hours performance for all patients by March 2024. Read full story (paywalled) Source: HSJ, 24 November 2023
  3. News Article
    Poor people and those with existing health problems are much more likely to die from sepsis, one of the UK’s biggest killers, a study has found. Sepsis, or blood poisoning, is a potentially fatal condition triggered when the body reacts to an infection by attacking its own tissues and vital organs. It leads to an estimated 48,000 deaths a year in Britain. Research from the University of Manchester has disclosed for the first time how some groups are at much higher risk of dying from the condition than the general population. An analysis of 248,767 cases of non-Covid sepsis in England between January 2019 and June 2022 has found that the most deprived people are twice as likely to die from it within 30 days. The findings, published in the journal eClinicalMedicine, also show that: People with learning disabilities are almost four times more likely to get sepsis. People with liver disease have about three times greater risk. Patients with chronic kidney disease that is at stage 5 are more than six times as likely to develop it. “This study shows socioeconomic deprivation, comorbidity and learning disabilities are associated with an increased risk of developing non-Covid related sepsis and 30-day mortality in England.” Read full story Source: The Guardian, 23 November 2023
  4. News Article
    Doctors have sent a stark warning over the dire state of emergency care for mental health patients after half of A&Es revealed patients were waiting more than five days in hospital before getting the treatment they need. The “truly alarming” figures, shared exclusively with The Independent, show vulnerable patients are being let down by “unacceptable delays” to their treatment, with one campaigner warning the issue has become a national emergency. The data, collated by the Royal College of Emergency Medicine (RCEM), prompted a bleak verdict from top doctor Dr Adrian Boyle who said the system – which sees patients being cared for by A&E staff who are not specifically trained for their needs – was failing the most “fragile” patients. Warning that mental health patients are being hit the hardest by long waits in A&E, Dr Boyle, the RCEM president, added: “These patients need effective and efficient care, they deserve compassionate care – crucially, they deserve better.” Read full story Source: The Independent, 20 November 2023
  5. News Article
    The system for sourcing medicines in England is broken and needs a fundamental overhaul to prevent shortages, senior pharmacists have told MPs. They were giving evidence at the first session of an inquiry by the Commons Health and Social Care Committee, which is exploring issues largely affecting community, primary care, and hospital pharmacy services. Dr Leyla Hannbeck, chief executive of the Association of Independent Multiple Pharmacies, told MPs that shortages of antibiotics, hormone replacement therapy, and medicines to treat attention deficit hyperactivity disorder over the past few years were symptomatic of "a real problem". Pharmacists constantly find that "medicines come on the market and then, all of a sudden as soon as the demand goes a little bit up, they are no longer available," she explained. She told the inquiry: "That indicates that something in the system is not right." Read full story Source: Medscape, 22 November 2023
  6. Content Article
    Beyond Compliance is a service to support the safe and stepwise introduction of new or modified implantable medical devices. An independent panel of experts, known as the Beyond Compliance Advisory Group, work with the implant manufacturer to assess the relative risk of any new product, and the rate at which it should be introduced to the market. The service collects data about patients who receive these implants and about their recovery following surgery. This data is made available to clinicians using the implant, to the manufacturer, and to independent assessors from the Beyond Compliance Advisory Group, to provide real-time monitoring of the implant’s performance. The clinicians who agree to joining the advisory group are drawn from the most experienced and respected members of their field. Beyond Compliance is an optional service available to implant manufacturers. The service commenced in the field of joint replacement implants. Following the success of the introduction of Beyond Compliance to Orthopaedic there are now plans for it to be extended for use with other implantable medical devices.
  7. Content Article
    The current NHS ‘cost improvement model’ is not sufficient to meet financial constraints, but an allocative efficiency approach being applied at Mersey Care Foundation Trust offers hope, its leaders argue. "34% of expenditure in health and care is attributable to just 8% of complex households, which raises real questions about the efficiency and effectiveness of our combined expenditure, and the waste of resources caused by the multiple contacts we offer to the same people and families without really addressing the root causes of their problems."
  8. Content Article
    In her latest blog, Patient Safety Commissioner Henrietta Hughes discusses MHRA's Yellow Card reporting system and why, until we have mandatory reporting, including for devices that are working as designed, we will continue to see avoidable harm occurring to patients. She stresses that it is vital that the voices and views of patients, clinicians, manufacturer, and health providers participate in the design and delivery of devices. 
  9. News Article
    An acute trust is launching its own social care service to reduce the ‘astronomical’ costs of delayed discharges. Harrogate and District Foundation Trust is among the first NHS providers to branch out into direct social care provision, in what the trust says is a “lift and shift” from the model adopted by Northumbria Healthcare FT. HDFT is now embarking on a six-month pilot of its new social care service. It comes as around 20 of the trust’s 300 beds are occupied by patients waiting for social care packages on a given day. Chief operating officer Russell Nightingale told HSJ delayed discharges are leading to patients who could have returned home with the right support deteriorating in hospital and ending up in care homes. Read full story (paywalled) Source: HSJ, 23 November 2023
  10. News Article
    Patients are being forced to pay for urgent eye care or risk going blind because of long NHS waits. MPs will today hear the scale of the “emergency” with four in five high street optometrists revealing their patients have paid for private procedures in the past six months. Dame Andrea Leadsom, the former House of Commons leader, business secretary and environment secretary, is being called on to commit to improving NHS eye care in her new role as public health minister. Four in five optometrists say they have patients waiting more than a year to be referred for an NHS appointment or treatment, according to analysis by the Association of Optometrists (AOP), leaving them at risk of going blind. About 640,000 people are waiting for an NHS ophthalmology appointment, more than any other speciality – accounting for about one in 11 people on the 7.8 million waiting list. About half of these people say their sight is deteriorating while they wait to be seen. Tens of thousands have been waiting more than a year, the AOP said. In a letter to Dame Leadsom, Adam Sampson, the chief executive of the AOP, said that high street optometrists should be used more widely across the NHS for “cataract surgery, help for glaucoma and age-related macular degeneration”. Mr Sampson said: “With the expansion of primary eye care services, more patients will have a better chance of receiving improved treatment, faster and locally, which could prevent avoidable irreversible sight loss.” Read full story (paywalled) Source: The Telegraph, 23 November 2023
  11. News Article
    Doctors must be on high alert for measles as vaccine rates among young children have dipped to a 10-year low, leaving some unprotected and risking outbreaks of the highly infectious and dangerous virus, experts say. It is the first time in decades the Royal College of Paediatrics and Child Health (RCPCH) has issued national guidance such as this. At least 95% of children should be double vaccinated by the age of five. But the UK is well below that target. Latest figures show only 84.5% had received a second shot of the protective measles, mumps and rubella (MMR) jab - the lowest level since 2010-11. Measles can make children very sick. The main symptoms are a fever and a rash but it can cause serious complications including meningitis. For some, it is fatal. The RCPCH is worried the UK is now seeing a "devastating resurgence" of virtually eliminated life-threatening diseases such as measles, because of low vaccine uptake. Read full story Source: BBC News, 22 November 2023
  12. Content Article
    A new report published by Carers Scotland shows the devasting impact the health and social care crisis is having on the health of Scotland’s 800,000 unpaid carers. 
  13. News Article
    A third of carers with poor mental health have considered suicide or self-harm, data shows. Figures given to the Liberal Democrats by Carers UK reveal that many of the UK’s millions of carers who look after relatives have bad mental health, with some “at breaking point”. In a survey of nearly 11,000 unpaid carers, the vast majority said they were stressed or anxious, while half felt depressed and lonely. More than a quarter said they had bad or very bad mental health. Of these, more than a third said that they had thoughts related to self-harm or suicide, while nearly three-quarters of those felt they were at breaking point. Helen Walker, the chief executive of Carers UK, said: “Unpaid carers make an enormous contribution to society, but far too regularly feel unseen, undervalued and completely forgotten by services that are supposed to be there to support them. “Not being able to take breaks from caring, being able to prioritise their own health or earn enough money to make ends meet is causing many to hit rock bottom.” Read full story Source: The Guardian, 22 November 2023
  14. News Article
    The trusts with the most patients waiting at least a week after they are ‘ready’ to be discharged can be identified for the first time, following publication of new NHS England data. The new collection shows how long patients are spending in hospital after being deemed fit for discharge, with around 3.7% of all patients in England waiting a week or longer in hospital following their “discharge ready” date — although about half trusts have so far failed to report accurate data. However, there is considerable variation across the country, with six trusts recording more than double the national average in terms of the proportion of patients declared medically fit for discharge being delayed by a week or more. Sarah-Jane Marsh, NHSE’s national director for urgent and emergency care, told HSJ in February that NHSE would aim to set a “baseline” for the discharge-ready data. HSJ understands NHSE will revisit the idea of a new target based on how long patients wait for discharge after they are “ready”, using the new collection, when more trusts are publishing data. It is also planning to publish data based on responsible local authority in future, given councils’ major role coordinating social care support for some people awaiting discharge. Read full story (paywalled) Source: HSJ, 23 November 2023
  15. Content Article
    An estimated 90,000 people are living with dementia in Scotland, with that number expected to increase to 164,000 by 2036. These national clinical guidelines from Health Improvement Scotland, the first to be published in nearly 20 years, provide recommendations on the assessment, treatment and support of adults living with dementia. It calls for greater awareness of pre-death grief for people with dementia, their carers and their loved ones, as they fear the loss of the person they know. To accompany the guidelines, a podcast has been produced by Health Improvement Scotland speaking to professionals, including Dr Adam Daly, Chair of Healthcare Improvement Scotland’s Guideline Development Group and a Consultant in old age psychiatry, and Jacqueline Thompson, a nurse consultant and the lead on pre-grief death for the guideline. We also hear from Marion Ritchie, a carer who experienced pre-death grief while caring for her husband.
  16. Content Article
    Presentation slides from Session 1 of the SEHTA 2023 International MedTech Expo & Conference. This session was on patient voice engagement. Presentations can be downloaded below.
  17. Content Article
    Reducing the amount of time to give antibiotics to sepsis patients should contribute to better health outcomes, but the broad impact of reducing time-to-antibiotics may vary significantly, according to an AHRQ-funded study. In the study, published in Annals of the American Thoracic Society, researchers found that in 60% percent of hospitalisations patients received antibiotics within 48 hours of presentation and in 13% of hospitalisations patients experienced an adverse event, based on records of over 1.5 million hospitalised patients. The authors then ran simulations of 12 hospital scenarios based on the volume of sepsis cases (high, medium and low volume), and found that the effect of faster time to antibiotics varies markedly across simulated hospital scenarios, but new antibiotic-associated adverse events were rare.
  18. News Article
    Health systems are still struggling to meet their financial plans, despite hundreds of millions being raided from investment budgets to help balance the books. Senior leaders in most regions said the cash falls short of their existing financial gaps. Earlier this month, NHS England announced that £800m would be made available to integrated care systems (ICSs) to offset the additional cost of strikes. HSJ understands ICSs reported a combined deficit that was £1.5bn worse than planned in the six months to October, which implies a gap of several hundred million pounds unless systems can report substantial surpluses for the second half of the year. HSJ spoke to senior sources in all seven regions, with more than half saying their systems would still fail to deliver breakeven, despite the funding transfers. A source in the South East said their system’s share of the funding “won’t touch the sides”, adding that NHSE was playing “hardball”. Another local source said they had identified a set of “nuclear options” to balance the books, but these would be “catastrophic for quality of care and/or nigh-on impossible to deliver”. Read full story (paywalled) Source: HSJ, 22 November 2023
  19. News Article
    Liquid bleach does not kill off a hospital superbug that can cause fatal infections, researchers have found. Clostridium difficile, also known as C diff, is a type of bacteria found in the human gut. While it can coexist alongside other bacteria without problem, a disruption to gut flora can allow C diff to flourish, leading to bowel problems including diarrhoea and colitis. Severe infections can kill, with 1,910 people known to have died within 30 days of an infection in England during financial year 2021-2022. Those at greater risk of C diff infections include people aged over 65, those who are in hospital, people with a weakened immune system and people taking antibiotics, with some individuals experiencing repeated infections. According to government guidance, updated in 2019, chlorine-containing cleaning agents with at least 1,000 ppm available chlorine should be used as a disinfectant to tackle C diff. But researchers say it is unlikely be sufficient, with their experiments suggesting that even at high concentrations, sodium hypochlorite – a common type of bleach – is no better than water at doing the job. “With antimicrobial resistance increasing, people need to recognise that overuse of biocides can cause tolerance in certain microbes, and we’re seeing that definitely with chlorine and C diff,” said Dr Tina Joshi, co-author of the research, from the University of Plymouth. While chlorine-based chemicals used to be effective at killing such bacteria, that no longer appears to be the case, she said. “The UK doesn’t seem to have any written new gold standard for C diff disinfection. And I think that needs to change immediately,” she said. Read full story Source: The Guardian, 22 November 2023
  20. News Article
    Engaging the private sector in delivering health care and goods requires a sound understanding of how to align resources with the strategic priorities of a health system. The WHO Regional Office for Europe and the European Observatory on Health Systems and Policies have released a new report for policy-makers that analyses governance evidence from the COVID-19 pandemic. “The question is not whether we should do it, but what we can do to do it well,” explained Dimitra Panteli, programme manager at the Observatory, who presented the policy brief during a WHO-hosted launch session at the European Public Health (EPH) Conference in Dublin. Having played a key part in the COVID-19 pandemic, the private sector showed that it holds resources and expertise that can enhance the delivery of health goods and services and help achieve Universal Health Coverage. It also has a wider role in the maintenance of essential health services and in ensuring health system resilience. “We cannot have the illusion that we should not work with the private sector, especially as health services struggle to cope with backlogs caused by the pandemic,” pointed out Natasha Azzopardi Muscat, Director of Country Health Policies and Systems at WHO/Europe. This collaboration can however present challenges, for example around governance practices. Policy successes and failures during the pandemic provide lessons for countries on how to engage the private sector in their health systems effectively. Read full story Source: European Observatory on Health Systems and Policies, 20 November 2023
  21. Content Article
    The latest Care Quality Commission (CQC) report on the state of care in England is far from an encouraging read.1 Although the healthcare system is under serious strain, maternity services are among the areas identified as especially challenged. The problems identified in maternity care, while shocking, come as no surprise. The sector is seeing repeated high profile organisational failures and soaring clinical negligence claims, together with grim evidence of ongoing variation in outcomes, culture, and workforce challenges and inequities linked to socioeconomic status and ethnicity. In this BMJ Editorial, Mary Dixon-Woods and colleagues discuss why it's time for a fresh approach to regulation and improvement.
  22. Content Article
    Whistleblowing presentation from Peter Duffy to the Association for Perioperative Practice, September 2022. York University.
  23. News Article
    The NHS has sparked controversy by handing the US spy tech company Palantir a £330m contract to create a huge new data platform, leading to privacy concerns around patients’ medical details. The move immediately prompted concerns about the security and privacy of patient medical records and the suitability of Palantir to be given access to and oversight of such sensitive material. NHS England has given Palantir and four partners including Accenture a five-year contract to set up and operate the “federated data platform” (FDP). The British Medical Association, which had previously voiced concern about the NHS’s alleged lack of scrutiny of bidders on “ethical” grounds, said Palantir’s winning bid was “deeply worrying”. NHS England sought to allay such concerns. It stressed that none of the companies in the winning consortium would be able to access health and care data without its explicit consent; that it would retain control of all data within the platform; and that it would not include GP data. It said the new software would be protected by the highest possible standards of security through the deployment of “privacy enhancing technology”. Read full story Source: The Guardian, 21 November 2023
  24. News Article
    Medics who are not qualified doctors have been used in senior roles at Birmingham Children's Hospital. Physician associates (PAs) have worked as the responsible clinician in the liver unit with a consultant on call. The RCPCH said it had heard the concerns of its members and the need for a clearly defined physician associate roles and training pathways. The doctors' union, the British Medical Association, called for a delay on recruitment of PAs until the group was properly regulated and supervised. The trust running the hospital said the physician associates did not work in isolation and only did the role with the right level of experience. Introduced in 2003, the PA role involved supporting doctors so they could deal with more complex patient needs. Usually, physician associates have a science degree and do a two-year post-graduate qualification. They are not doctors and are not allowed to prescribe drugs. The role is currently unregulated with the government planning legislation for regulations to be introduced before the end of 2024. PAs have worked at Birmingham Children's Hospital for 10 years but the BBC saw rotas which show them on tier two - normally a rota for senior doctors called registrars. PAs were not allowed to work unsupervised overnight and there were consultants on call at all times to offer advice, they said. Dr Fiona Reynolds, the trust's chief medical officer, insisted the safety and quality of care offered to children, young people and families remained a priority for everyone at the trust and would not be compromised. "Although small in number, [the PAs] skills and dedication to offering the best for our patients complements that of their colleagues in all fields - all of which are hugely valued by our trust," she added. Read full story Source: BBC News, 21 November 2023
  25. News Article
    The public inquiry into the Lucy Letby murders will seek changes to NHS services and culture next year despite the fact that formal hearings are likely to be delayed until the autumn. Inquiry chair Lady Justice Thirlwall will issue an update message later today. In it she will stress the inquiry will “look for necessary changes to be made to the system of neonatal care in this country in real time and at the earliest opportunity, avoiding delays in making meaningful change”. HSJ understands Lady Thirlwall will look to agree on some changes, based on the inquiry’s evidence gathering and discussions with the sector before it begins oral hearings – which are unlikely to start for at least a year due to ongoing legal action. Lady Thirlwall will say the legal constraints mean its early work will focus on the experience of families who were named in the cases already heard; and “on the effectiveness of NHS management, culture, governance structures and processes, as well as on the external scrutiny and professional regulation supposed to keep babies in hospital safe and well looked after”. She said, “I want this to be a searching and active inquiry in the sense that it will look for necessary changes to be made to the system of neonatal care in this country in real time and at the earliest opportunity, avoiding delays in making meaningful change”. Read full story (paywalled) Source: HSJ, 22 November 2023
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