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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The Department of Health and Social Care has published a letter, final report with recommendations, and a proposed code of practice framework from Baroness Hollins on the use of long-term segregation for people with a learning disability and/or autistic people. In her scathing report, Baroness Shelia Hollins said: “My heart breaks that after such a long period of work, the care and outcomes for people with a learning disability and autistic people are still so poor, and the very initiatives which are improving their situations are yet to secure the essential funding required to continue this important work."
  2. Event
    With the constantly evolving digital landscape in health and care, clinical safety has never been more important than it is now, and every health and care organisation and system supplier should have a Clinical Safety Officer to assess, prevent and address risks and hazards. PRSB and Ethos Ltd are delighted to offer you online training providing you with everything you need to become a certified Clinical Safety Officer. The one-day training programme includes a clinically led session on PRSB standards and their importance to delivering safe care. Why join? Learn in a small group and friendly environment (8-15 trainees per session) Get a comprehensive and in-depth understanding of the role of information standards in clinical safety The CPD UK accredited course equips you with the basic requirements of the DCB0129 and 0160 standards for clinical risk assessment and management. Register
  3. Event
    With the constantly evolving digital landscape in health and care, clinical safety has never been more important than it is now, and every health and care organisation and system supplier should have a Clinical Safety Officer to assess, prevent and address risks and hazards. PRSB and Ethos Ltd are delighted to offer you online training providing you with everything you need to become a certified Clinical Safety Officer. The one-day training programme includes a clinically led session on PRSB standards and their importance to delivering safe care. Why join? Learn in a small group and friendly environment (8-15 trainees per session) Get a comprehensive and in-depth understanding of the role of information standards in clinical safety The CPD UK accredited course equips you with the basic requirements of the DCB0129 and 0160 standards for clinical risk assessment and management. Register
  4. Event
    until
    With the constantly evolving digital landscape in health and care, clinical safety has never been more important than it is now, and every health and care organisation and system supplier should have a Clinical Safety Officer to assess, prevent and address risks and hazards. PRSB and Ethos Ltd are delighted to offer you online training providing you with everything you need to become a certified Clinical Safety Officer. The one-day training programme includes a clinically led session on PRSB standards and their importance to delivering safe care. Why join? Learn in a small group and friendly environment (8-15 trainees per session) Get a comprehensive and in-depth understanding of the role of information standards in clinical safety The CPD UK accredited course equips you with the basic requirements of the DCB0129 and 0160 standards for clinical risk assessment and management. Register
  5. Event
    until
    With the constantly evolving digital landscape in health and care, clinical safety has never been more important than it is now, and every health and care organisation and system supplier should have a Clinical Safety Officer to assess, prevent and address risks and hazards. PRSB and Ethos Ltd are delighted to offer you online training providing you with everything you need to become a certified Clinical Safety Officer. The one-day training programme includes a clinically led session on PRSB standards and their importance to delivering safe care. Why join? Learn in a small group and friendly environment (8-15 trainees per session) Get a comprehensive and in-depth understanding of the role of information standards in clinical safety The CPD UK accredited course equips you with the basic requirements of the DCB0129 and 0160 standards for clinical risk assessment and management. Register
  6. Event
    until
    With the constantly evolving digital landscape in health and care, clinical safety has never been more important than it is now, and every health and care organisation and system supplier should have a Clinical Safety Officer to assess, prevent and address risks and hazards. PRSB and Ethos Ltd are delighted to offer you online training providing you with everything you need to become a certified Clinical Safety Officer. The one-day training programme includes a clinically led session on PRSB standards and their importance to delivering safe care. Why join? Learn in a small group and friendly environment (8-15 trainees per session) Get a comprehensive and in-depth understanding of the role of information standards in clinical safety The CPD UK accredited course equips you with the basic requirements of the DCB0129 and 0160 standards for clinical risk assessment and management. Register
  7. Content Article
    Weekly briefings on the UK Covid-19 Inquiry summarising the proceedings most relevant to NHS trusts.
  8. Content Article
    Medical defence organisation MDDUS's latest annual member attitude survey has found that many have experienced or witnessed persistent racist microaggressions at work. Almost two-thirds of International Medical Graduate members report they’ve been subject to racist microaggressions and have little faith in being heard and the issue being taken seriously. MDDU's 'We hear you' campaign aims to be a catalyst for positive change and help rebuild confidence in the way such abuses can be reported.
  9. News Article
    One in 10 people attempting to contact their GP practice do not manage to get in contact, while a further 6% are only told to try again another day, according to new official survey findings commissioned by the government. The Office for National Statistics has been quietly carrying out the new regular GP access survey since the spring after ministers said they wanted to monitor the impact of their primary care recovery plan. After a sign of slight improvement in the summer, the latest survey results – for October – show no significant change since May. It also found, as did previous rounds, that of those who had tried to contact a GP practice in the past month, 10 per cent said they could not do so (see chart below, ‘Contact with GP practice’). Of those who did make contact, a further 6 per cent reported they were told to try again another day (see chart below, ‘Next step after contact’). The government and NHS England have made it a high priority in recovery plans that patients should no longer be asked to call back another day to book an appointment and should know “on the day” how their request will be managed, which may mean being advised to use a different service. Read full story (paywalled) Source: HSJ, 9 November 2023
  10. News Article
    An ex-minister has defended the government's approach to disabled people during the pandemic, following claims they were "largely disregarded". Justin Tomlinson, a former minister for disabled people, told the Covid inquiry the government recognised this group was at greater risk from the virus. He added that work had been done "at pace" to address this. The inquiry has previously been told that disabled people's views were not properly heard ahead of key decisions. Nearly six out of 10 people who died with coronavirus in England from January to November 2020 were disabled, according to the Office for National Statistics (ONS). In a witness statement published earlier this month, chief executive of charity Disability Rights UK, Kamran Mallik, said: "From the statements, decisions and actions of the UK government throughout the crisis, considerations relating to disabled people appeared to be largely disregarded." In his evidence earlier this month, Mr Mallik of Disability Rights UK said there was a "shocking disregard" when it came to providing information in alternative formats for disabled people, including letters on shielding for clinically vulnerable groups. He said his charity had also raised concerns about protections for care home residents, and help for disabled people who were not shielding but still needed support accessing food and essentials. Mr Mallik added that there had been no consultation to allow the views of charities or disabled people to be "properly heard before decisions were made". Read full story Source: BBC News, 8 November 2023
  11. News Article
    A high-profile shift to admitting patients from A&E to wards irrespective of bed capacity has ‘turned the dial’ for an acute trust’s emergency care, its chief executive has told HSJ. Since introducing the model in July last year North Bristol Trust has seen a significant improvement in its performance against the national target, with the number of patients seen within four hours rising from 51% to 72% in August 2023 – with a peak of 80% in April 2023. The model attracted interest from NHS England last year, as well as some concern from the Nuffield Trust over patient safety – but NBT CEO Maria Kane said the trust was “happy, on balance” with the system. She said the model “won’t be for everyone and we never claimed it would be” but she added: “Engendering whole hospital conversations about the principles of flow and understanding of [the emergency department] is something we could all do.” Read full story (paywalled) Source: HSJ, 8 November 2023
  12. Content Article
    Throughout this series of Fundamental Care podcasts, a panel of key opinion leaders and passionate healthcare staff from the UK will discuss and debate evidence based best practices at the core of the day-to-day challenges faced in healthcare, not only for patients but also for healthcare workers themselves.
  13. Content Article
    During a fellowship rotation in gynaecology, Rebekah Fenton, asked the attending physicians what pain management options they could offer patients for insertion of an intrauterine device (IUD). Their answer surprised her: none.  The research on the effectiveness of pain management techniques during the procedure were not strong enough to warrant providing potential relief.  But Fenton knew the attending physician was wrong: she'd received the drug lidocaine during a recent visit to her own ob/gyn to get an IUD placed. The local anesthetic enabled her to avoid the experiences of many patients who often withstand debilitating cramping and pain during insertion, side effects that can last for hours after the procedure has ended.  By not teaching her how to administer pain treatment options such as lidocaine gel or injection, "they made the decision for me, whether I could give patients this option," said Fenton, now an adolescent medicine specialist at Alivio Medical Center in Chicago. Related hub content: See our Pain during IUD fitting community thread.
  14. News Article
    NHS England ‘lacks a clear vision’ on a key part of its health inequalities agenda and is not holding trusts to account for delivering an ‘inclusive recovery’, a study by the King’s Fund has concluded. The think-tank’s report, which represents one of the most comprehensive analyses on the subject to date, said system leaders had not made the case for change “strongly or clearly enough to convince clinicians and other staff to consider inequalities” when tackling elective backlogs. The think-tank said it had undertaken the research to investigate to what extent local NHS organisations had taken an “inclusive approach” to managing waiting lists, as NHS England had ordered them to do in August 2020. The research team said in a statement alongside the report: “There has been a lack of a clear vision from national leaders on why inclusive recovery is important for delivering better and fairer services for patients and the public. “The report calls on the government to pay greater attention to inclusive recovery to ensure progress is made so that patients can be treated fairly, no matter their background.” Read full story Source: HSJ, 8 November 2023
  15. News Article
    Priory Healthcare faces legal action following the death of a vulnerable man who was hit by a train after leaving Birmingham’s Priory Hospital Woodbourne in September 2020. Matthew Caseby, 23, detained under the Mental Health Act, escaped the hospital by climbing a 2.3-metre fence. The inquest jury, which heard the University of Birmingham graduate should have been under constant observation but was left alone, reached a conclusion that his death “was contributed to by neglect”. Concerns were raised about the hospital's record-keeping, risk assessments, and fence safety. Following the inquest, the Care Quality Commission (CQC) charged Priory Healthcare with two offences under the Health and Safety Act 2008, related to failing to provide safe care and treatment, and exposing a patient to avoidable harm. Read full story Source: ITV, 6 November 2023
  16. News Article
    A woman who spent nine months in hospital waiting for a suitable care home placement became a "shadow of her former self", her mother has said. Jocelyn Ullmer, 60, from West Sussex, saw her health deteriorate after being admitted to hospital in June last year. Her mother, Sylvia Hubbard, 86, said: "We tried to get her out of hospital, but no-one wanted her." Across England, around 60% of patients classed as fit to leave remain in hospital at the end of an average day. Figures show the biggest obstacle is a lack of beds in other settings, such as care homes and community hospitals. The government said it was investing £1.6bn over the next two years to help improve the situation. Read full story Source: BBC News, 8 November 2023
  17. News Article
    Long waits in A&E departments may have caused around 30,000 ‘excess deaths’ last year, according to new estimates. Using a methodology backed by experts, HSJ analysis of official data has produced an estimate of 29,145 ‘excess deaths’ related to long accident and emergency delays in 2022-23, up from 22,175 in 2021-22, and 9,783 related deaths in 2020-21. For the first time, the analysis has also produced estimates of excess mortality related to long A&E delays for every acute trust. The data suggests the rate of excess deaths from 2022-23 has so far continued into 2023-24. The analysis followed a methodology used in a peer-reviewed study published in the Emergency Medicine Journal, which found delays to hospital admission for patients of more than five hours from time of arrival at A&E were associated with an increase in all-cause mortality within 30 days. Data scientist Steve Black, one of the authors of the EMJ study, said: “Long waits in A&E should never happen and 12-hour waits should be something like a never event. They should be intolerable anywhere. If we want to fix them it’s helpful to know which trusts have the worst problems with long waits.” Read full story (paywalled) Source: HSJ, 7 November 2023
  18. Content Article
    Structural, economic and social factors can lead to inequalities in the length of time people wait for NHS planned hospital care – such as hip or knee operations – and their experience while they wait. In 2020, after the first wave of the Covid-19 pandemic, NHS England asked NHS trusts and systems to take an inclusive approach to tackling waiting lists by disaggregating waiting times by ethnicity and deprivation to identify inequalities and to take action in response. This was an important change to how NHS organisations were asked to manage waiting lists – embedding work to tackle health inequalities into the process. Between December 2022 and June 2023, the King’s Fund undertook qualitative case studies about the implementation of this policy in three NHS trusts and their main integrated care boards (ICBs), and interviewed a range of other people about using artificial intelligence (AI) to help prioritise care. It also reviewed literature, NHS board papers and national waiting times data. The aim was to understand how the policy was being interpreted and implemented locally, and to extract learning from this. It found work was at an early stage, although there were examples of effective interventions that made appointments easier to attend, and prioritised treatment and support while waiting. Reasons for the lack of progress included a lack of clarity about the case for change, operational challenges such as poor data, cultural issues including different views about a fair approach, and a lack of accountability for the inclusive part of elective recovery. Taking an inclusive approach to tackling waiting lists should be a core part of effective waiting list management and can contribute to a more equitable health system and healthier communities. Tackling inequalities on waiting lists is also an important part of the NHS’s wider ambitions to address persistent health inequalities. But to improve the slow progress to date, NHS England, ICBs and trusts need to work with partners to make the case for change, take action and hold each other to account.
  19. News Article
    Lack of access to dentists is costing lives because mouth cancers are not being spotted or treated early enough, a health charity has told BBC News. The disease killed more than 3,000 people in 2021 - up 46%, from 2,075 a decade ago, latest figures obtained by the Oral Health Foundation show. And last year, a BBC News investigation revealed 90% of UK NHS dental practices were not accepting new adult patients. The government has announced plans to increase dental-training places by 40%. It also said the NHS was treating more people for cancer at an earlier stage than ever before. Oral Health Foundation chief executive Nigel Carter says dental check-ups "are a key place for identifying the early stage of mouth cancer". "With access to NHS dentistry in tatters, we fear that many people with mouth cancer will not receive a timely diagnosis," he adds. Read full story Source: BBC News, 8 November 2023
  20. News Article
    More than 150,000 adults and children with type 1 diabetes in England and Wales are to be offered an artificial pancreas on the NHS, which experts are hailing as a “gamechanger” that will “save lives and heartbreak”. The groundbreaking device, also called a hybrid closed-loop system, uses a hi-tech algorithm to determine the amount of insulin that should be administered and reads blood sugar levels to keep them steady. A world-first trial on the NHS showed it was more effective at managing diabetes than current devices and required far less input from patients. Final draft guidance from the National Institute for Health and Care Excellence (NICE) recommends that people in England and Wales should benefit from the wearable device if their diabetes is not adequately controlled by their current pump or glucose monitor. The decision to give the go-ahead for widespread use of the artificial pancreas was announced on Tuesday at NICE’s annual conference in Manchester by Dr Sam Roberts, its chief executive. The artificial pancreas has been found to be better at keeping blood sugar levels within a healthy range, cutting the risk of people suffering complications from diabetes. It works via a continuous glucose monitor sensor attached to the body which transmits data to a body-worn insulin pump. This pump then calculates how much insulin is needed and delivers the precise amount to the body. Hybrid closed-loop systems mean people do not need to rely on finger-prick blood tests or injecting insulin to control their blood sugar levels. Yasmin Hopkins, who took part in trials of the artificial pancreas, said: “From day one it was amazing. Before the closed-loop system, I would experience a lot of highs, which I’d then overcorrect, go low and eat a lot of sugar. All of that has been eradicated. “This technology gives me the freedom to get on with my life and live without fear of what might happen in a few hours, days or years.” Read full story Source: The Guardian, 7 November 2023 Related reading on the hub: How safe are closed loop artificial pancreas systems?
  21. Content Article
    High reliability organisations are organisations that work in situations that have the potential for large-scale risk and harm, but which manage to balance effectiveness, efficiency and safety. They also minimise errors through teamwork, awareness of potential risk and constant improvement. This evidence scan collates empirical evidence about the characteristics of high reliability organisations and how these organisations develop within and outside healthcare.
  22. Content Article
    Would you know what to do if something went wrong with your medical treatment in private/independent healthcare? This guide from PHIN tells what you should understand before choosing where to have your treatment and what to do if everything doesn’t go to plan.
  23. News Article
    Britain faces record shortages of medicines amid a row between drug makers and the NHS over payments. Patients face issues getting hold of drugs for epilepsy and ADHD, as well as hormone replacement therapy (HRT) for the menopause. A total of 111 drugs are currently facing supply issues, according to the British Generic Manufacturers Association (BGMA). This is the highest level on record and more than double the number of drugs facing shortages at the start of 2022. The BGMA blamed an NHS drugs levy for the supply issues, saying it was discouraging pharmaceutical companies from supplying the health service. Dr Leyla Hannbeck, chief executive of the Association of Independent Multiple Pharmacies, said pharmacists were “spending long hours in the day trying to source medicines for patients and this is on top of all the other activities they do in a busy pharmacy”. She said: “Our pharmacy teams see firsthand the anxiety and stress experienced by patients caused by medicines shortages.” Shortages have also led to more abuse and aggression towards pharmacists, she said. Read full story (paywalled) Source: The Telegraph,
  24. News Article
    The BMA’s GP committee for England (GPC England) has called for an immediate pause in the recruitment of physician associates (PAs) in general practice. In an emergency motion passed on 2 November the committee expressed “concerns over the increasing trend of PAs being used to substitute GPs” and called on practices and primary care networks to stop PA recruitment “until appropriately safe regulatory processes and structures are in place.” GPs and GP registrars were also reminded that they can refuse to sign prescriptions and turn down requests for investigations made by PAs. Read full story (paywalled) Source: BMJ, 3 November 2023
  25. News Article
    A former Pennsylvania nurse admitted she tried to kill 19 people at multiple different care facilities, piling dozens of new charges on the woman who allegedly administered lethal doses of insulin to numerous patients, killing two. On Thursday, the state's attorney general's office announced the new charges against Heather Pressdee, who now faces two counts of first-degree murder, 17 counts of attempted murder and 19 counts of neglect of a care-dependent person. The 41-year-old nurse was first arrested in May for killing two nursing home patients and injuring a third. From 2020 up until her arrest, prosecutors say Pressdee gave 19 patients at five different care facilities excessive amounts of insulin, some of whom were diabetic and needed it and others who did not. The plaintiff would typically administer these insulin doses overnight while fewer staff members were working and as "emergencies wouldn't prompt immediate hospitalization," Pennsylvania Attorney General Michelle Henry said. "If Pressdee sensed the victim would 'pull through' there is a pattern of her taking additional measures to try to kill the victims before they could be sent to the hospital by either administering a second dose of insulin or the use of an air embolism to ensure death," the criminal complaint, which also said Pressdee admitted to harming patients with intent to kill, said. Read full story Source: Scripps News, 3 November 2023
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