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
    Women are underrepresented in clinical trials, and even lab mice are predominantly male – and the effects show up in almost every aspect of human health Women are twice as likely as men to die from heart attacks; when a nonsmoker dies of lung cancer, it’s twice as likely to be a woman as a man; and women suffer more than men from Alzheimer’s and autoimmune disease. Yet research into these conditions, and many more, generally fails to examine women separately. It’s even less likely to look at disparities affecting women of color – why, for instance, Black women are nearly three times more likely to die in pregnancy than white women are. It’s been 30 years since the US Congress ordered the National Institutes of Health to make sure women were included equally in clinical trials. Despite some progress, research on women still lags, and there’s growing evidence that women and girls are paying the price. “Research on women’s health has been underfunded for decades, and many conditions that mostly or only affect women, or affect women differently, have received little to no attention,” the first lady Jill Biden said in announcing a new White House initiative on women’s health research on 13 November. “Because of these gaps, we know far too little about how to manage and treat conditions like endometriosis, and autoimmune diseases like rheumatoid arthritis. These gaps are even greater for communities that have historically been excluded from research – including women of color and women with disabilities.” Not only do researchers fail to include enough women in clinical trials, they often don’t look for differences between how men and women respond to treatments. Read full story Source: The Guardian, 20 November 2023 Further reading on the hub Dangerous exclusions: The risk to patient safety of sex and gender bias Gender bias: A threat to women’s health Animal testing doesn't work, we need to find new ways of testing the safety of medicines—a blog by Pandora Pound
  2. Content Article
    The BMJ’s new “practical prescribing” series aims to improve decision making Prescribing is one of the most fundamental parts of medicine and one of the most common interventions in health care. In the UK, the British National Formulary lists more than 1600 drugs. The number of prescriptions dispensed in the community in England grew by 66% from 686 million prescriptions in 2004 to 1.14 billion prescriptions in 2021-22.34 Polypharmacy has also increased, with around 15% of people in England taking five or more medicines a day and 7% taking eight or more medicines a day. The BMJ in conjunction with the Drug and Therapeutics Bulletin has commissioned a series of articles on practical prescribing. These articles will highlight important issues for prescribers to consider and prompts for shared decision making between prescribers, patients, and their carers. The series—targeted at all medical and non-medical prescribers, particularly doctors in training—will cover medicines commonly prescribed in primary and secondary care. The format is designed to help readers recall their understanding of a medication through a series of questions, exploring up-to-date evidence, and reviewing accessible information not readily found in prescribing texts.
  3. News Article
    There is a culture of impunity around sexual violence by healthcare staff in the NHS, with known perpetrators going unchallenged, campaigners have warned. A report by Surviving in Scrubs, a group of female doctors campaigning against misogyny in healthcare, said staff known to be perpetrators of sexual violence, who are most often senior male doctors, are tolerated or regarded as untouchable. The study, which analysed 174 incidents of staff-on-staff sexism, sexual harassment and sexual assault anonymously self-reported to the group’s website, found those who had been abused – mainly junior female doctors – struggled to get their complaints addressed. Some women said they faced threats of reprisals from those they were accusing. They reported feeling gaslit by colleagues who they said remained silent and, in some cases, colluded with the perpetrator. One woman referred to a perpetrator as the “Jimmy Savile of the surgical community”, and was told by a senior female colleague that “he was known for this behaviour, that he’d got away with so much before and he was capable of ruining careers”. Of the 209 incidents reported to Surviving in Scrubs since it launched last summer, just over 42% (89) were sexual harassment, a fifth (43) were sexual assaults, nearly 2% were rapes, and almost 37% (77) concerned sexist behaviour. Some incidents were recorded in more than one category. Dr Becky Cox, the co-founder of Surviving in Scrubs, said a culture of sexism and sexual abuse had become normalised in the NHS. “When you’re [a woman] coming into this profession, you see senior male consultants who are derogatory, use sexist language, and assault you. Male medical students see this behaviour and think that’s normal. Then they go up the ranks and continue to perpetrate the behaviour. It’s a never ending cycle.” Read full story Source: The Guardian, 21 November 2023 Related reading on the hub Calling out the sexist and misogynist culture within healthcare: a blog by Dr Chelcie Jewitt, co-founder of the Surviving in Scrubs campaign
  4. Content Article
    Surviving in Scrubs have published their first report 'Surviving healthcare: Sexism and sexual violence in the healthcare workforce' is now live. The report is an analysis of 150 survivor stories submitted to their website since they launched in 2022. It details the findings on the incidents, factors and challenges unique to healthcare that permit sexism and sexual violence in the healthcare workforce. The report contains recommendations to healthcare organisations to better support survivors and end these behaviours.
  5. News Article
    UK officials are to meet with counterparts in Turkey following the death of a British woman during so-called Brazilian butt lift surgery at a private hospital in the country’s capital Istanbul. Melissa Kerr, 31, from Gorleston in Norfolk, travelled to the private Medicana Haznedar hospital for the buttock enlargement surgery in 2019. She died at the hospital on the day of the surgery, which involves fat taken from elsewhere on the body being injected into the buttocks. An inquest into her death, which took place place in Norwich earlier this year, heard that Kerr, who was self-conscious about her appearance, was given only “limited information regarding the risks and mortality rate” associated with the operation. Jacqueline Lake, the senior coroner for Norfolk, wrote to the health secretary expressing concern about people travelling overseas for cosmetic surgery. In a written response to Lake, health minister Maria Caulfield confirmed UK officials would be travelling to Turkey to meet with their counterparts. “The intention is to discuss the regulatory framework, and the protections that are in place for UK nationals, and to identify concrete areas where the UK and Turkish authorities should work together to reduce the risks to patients in the future,” Caulfield says in the letter first reported by the BBC. “Specifically, I have noted in your report the lack of standard pre-assessment questions provided to Ms Kerr in Türkiye. “We remain aware countries providing healthcare tourism often conduct pre-assessment checks that may not match UK regulatory standards and we want to encourage all providers treating UK nationals to meet international best practices on pre-operative procedures whenever possible. “Such transparency and standardisation are important to reduce potential risks to patients and improve patient care in the UK and overseas." Read full story Source: The Guardian, 21 November 2023
  6. News Article
    Calls are being made to improve NHS interpreting services, with staff resorting to online translation tools to deliver serious news to non-English speaking patients. The National Register of Public Service Interpreters said "poorly managed" language services are "leading to abuse, misdiagnosis and in the worst cases, deaths of patients". The BBC's File on 4 programme has found interpreting problems were a contributing factor in at least 80 babies dying or suffering serious brain injuries in England between 2018 and 2022. NHS England says it is conducting a review to identify if and how it can support improvements in the commissioning and delivery of services. Rana Abdelkarim and her husband Modar Mohammednour arrived in England after fleeing conflict in Sudan, both speaking little English. It was supposed to be a fresh start but they soon suffered a devastating experience after Ms Abdelkarim was called to attend a maternity unit for what she thought was a check-up. In fact, she was going to be induced, something Mr Mohammednour said he was completely unaware of. "I heard this 'induce', but I don't know what it means. I don't understand exactly," he said. His wife suffered a catastrophic bleed which doctors were unable to stem and she died after giving birth to her daughter at Gloucestershire Royal Hospital in March 2021. He said better interpreting services would have helped him and his wife understand what was happening. "It would have helped me and her to take the right decision for how she's going to deliver the baby and she can know what is going to happen to her," he added. The Healthcare Safety Investigation Branch (HSIB) found there were delays in calling for specialist help, there was no effective communication with Ms Abdelkarim, and the incident had traumatised staff. Gloucestershire Royal Hospitals NHS Foundation Trust has apologised and said it had acted on the coroner's recommendations to ensure lessons have been learned to prevent similar tragedies. Read full story Source: BBC News, 21 November 2023
  7. Content Article
    The World Health Organization (WHO) has published the third edition of the Mental Health Gap Action Programme (mhGAP) guideline which includes important new, and updated, recommendations for the treatment and care of mental, neurological and substance use (MNS) disorders. MNS disorders are major contributors to morbidity and premature mortality in all regions of the world. Yet it is estimated that over 75% of people with MNS disorders are unable to access the treatment or care they need. The mhGAP guideline supports countries to strengthen capacity to deal with the growing burden of these conditions. It is intended for use by doctors, nurses, other health workers working in non-specialist settings at primary health care level, as well as health planners and managers.
  8. Content Article
    This is the protocol for a Campbell systematic review. The main aim of this systematic review was to identify whether hospital leadership styles predict patient safety as measured through several indicators over time. The second aim was to assess the extent to which the prediction of hospital leadership styles on patient safety indicators varies as a function of the leader's hierarchy level in the organisation.
  9. Content Article
    With Whitehall paymasters showing less faith in the organisations that hold the budgets for health and social care in England, Mark Dayan describes five ways that such tensions behind the scenes can impact on the running of services: Promising and planning. Ministerial direction. Frontline first. Too much too late. Enough already.
  10. News Article
    Patients are being left feeling “confused and neglected” by not being told who to contact about their future care when they are discharged from hospital, an NHS watchdog has said. Research by Healthwatch England has found that 51% of people are not being given details when they leave of which services they can turn to for help and advice while they are recovering. The NHS was risking patients having to be readmitted as medical emergencies and hospital beds becoming even more scarce by failing to adhere to its own guidelines on discharge, it said. “While our findings show some positive examples, it’s alarming that guidance on safe discharge from the hospital is routinely not being followed,” said Louise Ansari, the patient champion’s chief executive. Healthwatch asked 583 people and their carers how their discharge had gone. Read full story Source: The Guardian, 19 November 2023
  11. Content Article
    New research from Healthwatch reveals worrying problems with hospital discharge arrangements. Many people told us they are not given the right support or information when being discharged from hospital. Read on about their experiences and Health Watch's calls to action.
  12. Content Article
    A service providing bilingual medication information is helping to reduce healthcare inequalities and medical errors. Pharmacies across London are benefitting from the support of Written Medicine; a service providing bilingual dispensing labels in patients’ language of choice.
  13. News Article
    The BMA has called for an immediate halt to the recruitment of Medical Associate Professionals (MAPs) in the UK including Physician Associates (PAs) and Anaesthetic Associates (AAs). Doctors from across the UK who make up the BMA’s UK Council have passed a Motion which calls for the moratorium on the grounds of patient safety. They want the pause to last until the government and NHS put guarantees in place to make sure that MAPs are properly regulated and supervised. The move follows a number of recent cases in which patients have not always known they were being treated by a physician associate and tragically have come to harm. Professor Phil Banfield, BMA chair of council, said: “Doctors across the UK are getting more and more worried about the relentless expansion of the medical associate professions, brought into sharp focus by terrible cases of patients suffering serious harm after getting the wrong care from MAPs. Now is the time for the Government to listen before it is too late. We are clear: until there is clarity and material assurances about the role of MAPs, they should not be recruited in the NHS. “We have always been clear that MAPs can play an important part in NHS teams, and doctors will continue to value, respect and support individual staff they work with. But MAPs roles and responsibilities are not clearly defined. We are seeing increased instances of MAPs encroaching on the role of doctors; they are not doctors, do not have a medical degree and do not have the extensive training and depth of knowledge that doctors do. As doctors, we are worried that patients and public do not understand what this could mean in respect of the level of experience and expertise in care they receive. “The General Medical Council is the exclusive regulator of doctors in the UK. Adding staff who are not doctors and do not have a medical degree to the GMC register brings into question the competence and qualification of the whole medical profession. The Government may view this as a price worth paying for a shortcut to solving the workforce crisis they have presided over. We know otherwise. GMC regulation of MAPs will only add to the confusion and uncertainty that patients face. “Ministers may hope that by using secondary legislation, which may not even require the vote of MPs, they can avoid raising the alarm. But patients want doctors to remain doctors, regulated by a dedicated body, and they have a right to have confidence in the expert medical care they receive. There must be no doubt that when a patient goes to see a doctor, they are going to see a doctor. This blurring of roles and the confusion caused to patients must stop now.” Source: BMA, 16 November 2023
  14. Content Article
    The government recently published terms of reference for the Thirlwall Inquiry following the crimes committed by former neonatal nurse Lucy Letby while working for the Countess of Chester Hospital NHS Foundation Trust. As well as examining the detail of the offences, the inquiry will also probe whether the trust’s culture, management, governance structures and processes contributed to the failure to protect babies. In the wake of this tragedy, it became apparent that staff had sounded the alarm about Lucy Letby, but that their concerns were not acted on. The case has propelled the issue of NHS management structures and the regulation of managers back into the headlines and made it the subject of political debate. 
  15. Event
    until
    Patient Safety Movement Foundation invites you to the 11th World Patient Safety, Science & Technology Summit. Patient safety thought leaders and advocates from around the globe will come together to share their expertise and develop transformative solutions to enhance safety and outcomes of care for patients worldwide. Register
  16. Content Article
    The Care Quality Commission's (CQC) annual report on their work to enforce the Ionising Radiation (Medical Exposure) Regulations in England has been published. The regulations protect people from the dangers of being accidentally or unintentionally exposed to ionising radiation in a healthcare setting. Errors can happen when healthcare providers use ionising radiation to diagnose or treat people. Healthcare providers must notify CQC about these. The report gives a breakdown of the number and type errors that CQC was notified about between 1 April 2022 and 31 March 2023. The report also presents the key findings from our inspection and enforcement activity in that time.
  17. Content Article
    US healthcare organisations continue to grapple with the impacts of the nursing shortage—scaling back of health services, increasing staff burnout and mental-health challenges, and rising labour costs. While several health systems have had some success in rebuilding their nursing workforces in recent months, estimates still suggest a potential shortage of 200,000 to 450,000 nurses in the United States, with acute-care settings likely to be most affected.1 Identifying opportunities to close this gap remains a priority in the healthcare industry. This article highlights research conducted by McKinsey in collaboration with the ANA Enterprise on how nurses are actually spending their time during their shifts and how they would ideally distribute their time if given the chance. The research findings underpin insights that can help organizations identify new approaches to address the nursing shortage and create more sustainable and meaningful careers for nurses.
  18. News Article
    NHS England has taken the unusual move of warning multiple GP practices they are breaching their contract by refusing to give people automatic access to future entries in their record. Under the current national GP contract, practices were ordered to give people on their list automatic access to prospective (future) medical records, via the NHS App, by 31 October. However, the British Medical Association GP committee has urged GPs to instead adopt an “opt in” model, saying it is concerned that giving automatic access could endanger some people. The BMA gave practices a template letter to use to tell their integrated care boards they cannot move ahead with automatic access “due to several risks that cannot be sufficiently mitigated”. NHS England’s own template letter for ICBs to use in response, seen by HSJ, states: “Based on your letter we interpret that the required changes were not implemented by 31 October 2023, thereby putting you in breach of your contractual obligations. We would therefore like to discuss with you your plan, including the timeline to become compliant.” It is an unusual warning from NHSE which could potentially apply to hundreds or thousands of practices. Read full story (paywalled) Source: HSJ, 16 November 2023
  19. News Article
    The NHS should better track patients with the greatest clinical need so they can move to the front of the queue for treatment, a former government waiting list tsar has said. Anthony “Mac” McKeever told HSJ the health service could improve how it works through its elective backlog by using a system introduced during the covid pandemic to prioritise the most pressing cases. He said a “large chunk” of cases were still not given a code to say how long they are considered to be able to wait for surgery, which is at the heart of this process. Mr McKeever retired as Mid and South Essex Integrated Care Board chief executive this month following nearly five decades in the health service, including as a trust leader. Although Mr McKeever said he only knew the regional situation for the East of England, he would be “very surprised” if the national picture was any different. Waiting list expert Rob Findlay agreed this was a reasonable assumption. Read full story (paywalled) Source: HSJ, 17 November 2023
  20. News Article
    The nursing watchdog will miss its target to tackle a 5,500-case backlog of complaints as referrals hit a record high. The Nursing and Midwifery Council NMC has admitted it won’t hit its pledge to cut the number of unresolved complaints against nurses and midwives to 4,000 by March 2024. The news comes as it faces questions over the way it handles complaints after The Independent revealed a number of serious allegations, including poor investigations that have led to fears of rouge nursing going unchecked. The newspaper exposes have prompted two independent reviews. Details of the first two reviews have been revealed for the first time and will look at: The NMC’s response to whistleblower concerns, including whether they were treated fairly and whether it acted fairly and reasonably. Any evidence of cultural issues which may have impacted the NMC’s response to whistleblowing. Whether concerns raised are substantiated and indicate a decision-making process by the NMC which is insufficient in protecting the public. Evidence of shortcomings in guidance and training. The senior whistleblower whose evidence prompted the review said: “The NMC has refused to change its approach to the investigations into my whistleblowing concerns to allow me to share and explain my evidence without fear of reprisal. I don’t think it is possible to draw safe conclusions about either how I have been treated or the impact of our culture on case work from reviewing only 13 of our current 5,500 open cases, and 6 closed cases and a selection of my emails.” Read full story Source: The Independent, 16 November 2023
  21. News Article
    Forcing some medical staff to work through industrial action under new anti-strike laws could end up harming patient care, hospital trust leaders have said, as ministers claimed their new measures would keep public services running over Christmas. NHS Providers, which represents hospital, mental health and ambulance trusts, said there was a significant risk it would damage relationships between staff and employers that are already very challenged, in a way that could affect patients. In a submission to the consultation on minimum service levels in hospitals, it said: “Our key concern is that rather than strengthening services as intended, the legislation proposed would worsen relationships between employers and staff, and between trusts and local union representatives to the longer-term detriment of patient care.” Read full story Source: The Guardian, 17 November 2023
  22. News Article
    Women experiencing hot flushes, night sweats, depression and sleep problems could be offered therapy to help reduce their menopause symptoms, under new guidelines. But menopause champions warned that those suffering with symptoms could have long waits for mental health support and stressed that the new draft guidance to GPs from the National Institute for Health and Care Excellence (NICE) must not distract from “ongoing challenges” of getting HRT. A NICE evidence review found that cognitive behavioural therapy (CBT) can help make night-time sweats less severe and frequent and should be considered “alongside or as an alternative to HRT”. The guidance is not mandatory but GPs will be expected to take the new guidance “fully into account”, said Nice. Caroline Nokes, chair of the Commons’ women and equalities committee, welcomed the new guidance saying there was no “one size fits all” to help women going through the menopause, but said it must not be used to fob off women, some of whom were still facing drug shortages. A major HRT drug shortage last year resulted in 22 restrictions being put in place, pushing some women to turn to the hidden market or meet up with other women to buy, swap or share medicines. Read full story Source: The Guardian, 17 November 2023
  23. News Article
    Loughborough University is collaborating with NHS England to deliver learning to hundreds of healthcare professionals in a bid to improve patient safety. Human factors and ergonomics experts in the School of Design and Creative Arts will deliver Levels 3 and 4 of the NHS Patient Safety Syllabus and Curriculum after winning a competitive tender process. Under the leadership of Dr Mike Fray, supported by Professor Sue Hignett and Professor Thomas Jun, the Loughborough University team will craft and deliver educational content to 820 patient safety specialists across various NHS Trusts in England from 2023 to 2024. In 2021, the NHS Patient Safety Syllabus was created by drawing upon best practice from a number of safety-critical industries. It has as a core aim of changing how staff think about improving patient safety. The key to this is switching the focus to proactive prevention of safety incidents, and away from the current largely retrospective analyses. Dr Fray believes Loughborough University’s world-leading reputation in the delivery of human factors and ergonomics education will help the NHS achieve its goals. Dr Fray said: “No healthcare worker goes to work thinking they will do harm, but the systems, processes and complexity of the work can lead to errors, omissions, or reductions in quality of care. “With this new course we will be able to support patient safety specialists in each Trust to lead safety improvement work and provide safety science expertise to their organisations so that patients across the NHS can benefit.” Aidan Fowler, National Director of Patient Safety said: ‘’Training and education is at the centre of the NHS Patient Safety Strategy so that we can empower people with the latest skills and knowledge in patient safety science. “The launch of this training for our patient safety specialists is the latest development in this work, using the syllabus created with the Academy of Medical Royal Colleges and adding to the training already available to all staff in the NHS.” Read full story Source: Loughborough University, 15 November 2023
  24. Content Article
    Ambulatory infusion pumps are small, battery powered devices that allow patients to carry out day-to-day activities while receiving medication. They are used for many healthcare needs, including symptom relief during palliative care, and in different settings including hospitals, hospices and patients’ homes. Despite having audio and visual warning alarms to notify when medication is not being delivered as it should be, there is a risk that alarms can go unnoticed, particularly by healthcare staff in inpatient settings. The patient case in the Health Services Safety Investigations Body (HSSIB) investigation report is Stephen, a 45-year-old cancer patient on palliative care in hospital, who did not receive his pain relief medication for six hours. Over the course of six hours, there were eight warnings.
  25. News Article
    Almost half a million women will be able to get the contraceptive pill from pharmacies in England, from next month, without the need for a GP appointment. Treatments for urinary infections and other common conditions will also be on offer under the Pharmacy First scheme. NHS England said it was a safe and common-sense way of making NHS services easier for patients to use. New Health and Social Care Secretary Victoria Atkins said the changes meant "more options for women when making a choice about their preferred contraception" and would free up GP appointments. From February, pharmacists who successfully apply to join the scheme will be able to offer advice and treatment, including antibiotics, for seven common conditions: sinusitis sore throat earache infected insect bites impetigo shingles urinary tract infection in women. Read full story Source: BBC News, 16 November 2023
×
×
  • Create New...