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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Health at a Glance provides a comprehensive set of indicators on population health and health system performance across OECD members and key emerging economies. These cover health status, risk factors for health, access to and quality of healthcare, and health system resources. Analysis draws from the latest comparable official national statistics and other sources. Alongside indicator-by-indicator analysis, an overview chapter summarises the comparative performance of countries and major trends. This edition also has a special focus on digital health, which measures the digital readiness of OECD countries’ health systems, and outlines what countries need to do accelerate the digital health transformation.
  2. Content Article
    Recently, in the wake of growing unrest, plummeting morale, and industrial action, doctors have created an increasingly hostile narrative towards physician associates (PAs) on social media and raised repeated concerns about their impact on patient safety and training opportunities. In this BMJ opinion piece, David Oliver looks at the recent history to understand how we got here and discusses why we need a mature debate about these matters otherwise interprofessional solidarity and multidisciplinary team working could be harmed by the degree of vitriol and resentment.
  3. News Article
    Drug that can halve breast cancer risk offered to 289,000 women in England Anastrozole to be made available to women who have been through the menopause and have family history of breast cancer Almost 300,000 women at higher risk of developing breast cancer are being given access to a drug that can halve their risk in a “major step forward” in the fight against the disease. An estimated 289,000 women in England who are at moderate or high risk of breast cancer will from Tuesday be able to take the tablet to try to prevent it from developing, NHS bosses said. The drug, anastrozole, is being made available to women who are in greater danger because they have been through menopause and have a major family history of Britain’s commonest form of cancer. It displays “remarkable” potential to reduce the number of people who go on to develop the disease, the head of the NHS said last night. Every year, around 56,000 women in the UK are diagnosed with breast cancer – about 150 a day. While survival rates have improved, it still claims about 11,500 lives each year. “It’s fantastic that this vital risk-reducing option could now help thousands of women and their families avoid the distress of a breast cancer diagnosis,” said Amanda Pritchard, NHSC England’s chief executive. The drug will be taken as a 1mg tablet once a day for five years. Read full story Source: The Guardian, 7 November 2023
  4. News Article
    A mental health trust at the centre of several care scandals has ‘turned the dial’ on improvement, its chief executive has said, following the Care Quality Commission noting some progress but retaining a ‘requires improvement’ rating The CQC said earlier this month that improvements had been made at some services at Tees Esk and Wear Valleys Foundation Trust, including for its forensic secure inpatient service, where the rating was raised from “inadequate” to “good”. But the improvements were not enough to shift its overall “requires improvement” rating. Chief executive officer Brent Kilmurray argued the CQC report was evidence the trust was going in the right direction following a number of highly critical reports relating to patient deaths, but he also told HSJ it was a “challenge” for the trust to “tell a balanced story around where we are making progress”. TEWV has recently admitted care failings relating to the deaths of two inpatients in 2019 and 2020, following prosecution from the CQC. The trust will go on trial for alleged failings relating to another death in February next year. Read full story (paywalled) Source: HSJ, 6 November 2023
  5. News Article
    Maternity services at Hull Royal Infirmary have recently been described in a damning report by the health watchdog as chaotic, unsafe and not fit for purpose. Three mothers, who claim staff missed signs of life-threatening conditions that could have killed them or their babies, have spoken to the BBC about their harrowing experiences at the hospital. One woman, a BBC journalist who does not want to be named, said she knew her newborn son was seriously ill within minutes of giving birth at the infirmary in 2021. "As soon as they handed him to me, I noticed something was wrong. He was panting and his breathing wasn't right," she said. Over the course of an hour, she said her concerns were dismissed by the newly-qualified midwife who said his breathing was "completely normal". "She kept reassuring me over and over that's how babies breathe. I felt like I was drowning surrounded by lifeguards," she said. But after being examined by a more experienced midwife, the baby was rushed to intensive care and diagnosed with potentially fatal sepsis. "It was like time stood still. The midwife ripped him off me and she slammed an oxygen mask on his face, called the crash team and he was taken away to the neonatal intensive care unit. "The anger I felt was overwhelming because I'd been saying for nearly an hour he was seriously ill. I was right and he had sepsis." A few months after her son's birth, she read about an inquest into the death of a four-day-old baby who had sepsis and was born at Hull Royal Infirmary. A coroner found that midwives had failed to respond to his infection quickly enough. "My blood ran cold because it was exactly the same circumstances that happened to me and that baby died. I thought they clearly haven't learned anything," she said. Read full story Source: BBC News, 6 November 2023
  6. News Article
    Pregnant women across the Democratic Republic of the Congo are to be offered free healthcare in an effort to cut the country’s high rates of maternal and neonatal deaths. Women in 13 out of 26 regions in the country will, by the end of the year, be entitled to free services during pregnancy and for one month after childbirth. Babies will receive free healthcare for their first 28 days under the scheme, which the government plans to extend to the rest of DRC – although there is no timetable for that yet. However, health workers have raised concerns that hospitals and medical centres are ill-equipped to cope with any increased demand on services. Some told the Guardian there were not enough staff, facilities or equipment to successfully introduce the $113m (£93m) programme, which is supported by the World Bank. The rollout of the programme comes amid nationwide strikes by nurses, midwives, technicians and hospital administrative staff, who are calling for higher pay and better conditions. Congo has one of the highest number of maternal and neonatal deaths in the world. Latest figures record the maternal morality ratio at 547 deaths for every 100,000 live births, and its neonatal rate – the number of babies dying before 28 days of life – at 27 per 1,000 live births. The minister of public health, Roger Kamba Mulamba, said the programme would free women from a “prison sentence”. He said: “Mothers today get healthcare without fear when they are pregnant. Babies today do not die because they have no access to antibiotics. Mothers today do not die because they cannot afford to pay for a caesarean delivery.” Read full story Source: The Guardian, 6 November 2023
  7. Event
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    Antimicrobial resistance (AMR) is a clear and growing threat to health. Antibiotics are the cornerstone of modern medicine, but AMR has implications for the effective treatment of an increasing range of infections, with potential consequences for the future of health services not just in the UK but across the world. This free online event from the King's Fund will provide an opportunity to discuss why AMR matters, the impact of the UK’s approach to tackling it so far, and what more needs to be done. This event takes place in the context of the government’s 20-year vision for antimicrobial resistance and ongoing work to develop the upcoming 2024–29 national action plan for AMR as the current action plan comes to an end. This panel discussion will bring together experts to discuss: past and current efforts to tackle AMR in the UK and their impact – such as supporting the optimisation of antibiotic prescribing, developing new antibiotics, and improving the pipeline, and maximising the use of diagnostics the impact UK actions can have on a global issue such as AMR and stewardship at an international level what more should the UK be doing, how to understand the barriers that prevent effective action, and the levers that are available to drive progress as the UK moves into the next phase of the 20-year vision for AMR? Register
  8. Content Article
    People with chronic pain need personalised care – an approach offering patients choice and control over their mental and physical health, basing care on what matters to them personally, and focusing on individual strengths and needs. People in this position need someone to listen and acknowledge that these symptoms are real, not all in their head. They need someone to explain their chronic pain and other symptoms, but also someone for everything else too. As well as medical care, people need time and emotional care. But how on earth can this be achieved in UK primary care in 2023? Is this really the role of a modern GP? Even if it was how can it now be in our over-stretched, fragmented, target-driven services? In North-West London, Selena Stellman and Benjamin Ellis have tested a personalised care model to improve the care offered to patients with fibromyalgia and high impact chronic pain. In this opinion piece in BJGP Life, they discuss the two key changes in their approach.
  9. Content Article
    The National Patient Safety Improvement Programmes (SIPs) collectively form the largest safety initiative in the history of the NHS. They support a culture of safety, continuous learning and sustainable improvement across the healthcare system. SIPs aim to create continuous and sustainable improvement in settings such as maternity units, emergency departments, mental health trusts, GP practices and care homes. SIPs are delivered by local healthcare providers working directly with the National Patient Safety Improvement Programmes Team and through 15 regionally-based Patient Safety Collaboratives. The five National Patient Safety Improvement Programmes (NatPatSIP) are as follows: Managing Deterioration Safety Improvement Programme (ManDetSIP) Maternity and Neonatal Safety Improvement Programme (MatNeoSIP) Medicines Safety Improvement Programme (MedSIP) Adoption and Spread Safety Improvement Programme (A&S-SIP) Mental Health Safety Improvement Programme (MH-SIP) This report summarises the progress of the National Patient Safety Improvement Programmes.
  10. News Article
    Doctors are warning that patient safety is being put at risk as podiatrists and pharmacists replace GPs “on the cheap”. Dozens of family doctors have contacted The Telegraph claiming that talk of a GP shortage is “a big lie” and that they are being replaced by less qualified, cheaper staff, in a “crisis”. Documents seen by The Telegraph show staff including podiatrists, pharmacists and physician associates being used in lieu of GPs to diagnose and treat patients with conditions they are not trained in. In the most extreme cases, poorly children with viral infections, asthma-related issues and concerns about menstruation have been seen and diagnosed by a podiatrist – a healthcare professional trained exclusively to care for feet. It is not clear what happened to any of the patients afterwards, or if their parents were aware they had seen a podiatrist rather than a doctor. One GP said it was “a matter of patient safety” and the notion of “everything being supervised” did not work at a GP practice like it does in hospitals. Read full story (paywalled) Source: The Telegraph, 4 November 2023
  11. News Article
    A private health company paid millions by the NHS has failed to fix safety defects that led to the death of a cancer patient, the Guardian can reveal. Three patients were hospitalised and a fourth died when they were given the wrong doses of a powerful chemotherapy drug after a catastrophic IT failure at the medicine manufacturing unit of Sciensus in April this year. The incident, first revealed by the Guardian in July, prompted an investigation by the Medicines and Healthcare products Regulatory Agency (MHRA). Its inspectors found “significant deficiencies” at the Sciensus manufacturing facilities and ordered the partial suspension of its manufacturing licence. However, six months after the IT blunder, Sciensus has not fixed the problems identified by the regulator, according to people familiar with the matter. As a result, the suspension of its licence – originally due to be lifted last month – has been extended until July next year. Sciensus is the UK’s biggest provider of medicines services to NHS and private patients at home. It is contracted by the NHS and other organisations to deliver and administer medicines to more than 200,000 people with conditions such as heart disease, diabetes, dementia, HIV and cancer. Read full story Source: The Guardian, 5 November 2023
  12. News Article
    ‘Chronic short-termism’ by government is undermining the nation’s ability to respond to another pandemic, a previous NHS England chief executive has said. In his first written statement to the covid public inquiry, Lord Stevens said ministers had failed to upgrade NHS infrastructure and modernise social care, delayed public health improvements, and cut testing and research programmes. This is despite the 2023 national risk register identifying a further pandemic as the highest risk, with “5-25%pa Lord Stevens – NHSE CEO from 2014 to summer 2021 – said it was “encouraging the government has now permitted NHS England to publish a funded long-term workforce plan”, but added: “There is also a strong case for revisiting several other national decisions. “These include the dismantling of some community infection surveillance infrastructure; cancelling some scientific and clinical research programmes developed during the pandemic; postponing various preventative health measures; deferring reform of social care; and further delaying upgrades of health buildings, equipment and technology.” Read full story (paywalled) Source: HSJ, 3 November 2023
  13. Event
    The National Conference on Men and Boys Issues 2023 is brought to you by The Men and Boys Coalition and Men's Day UK, with sponsorship from Besin's Healthcare. Register
  14. News Article
    Patients and their relatives will be able to request a second opinion from senior medics around the clock when the “Martha’s rule” system starts in hospitals in England. The government’s patient safety commissioner, asked by the health secretary, Steve Barclay, to advise on how to implement the change, has said access to a medic’s opinion must operate 24/7. Dr Henrietta Hughes made clear to Barclay in a letter that inpatients and families worried that their loved one’s health is deteriorating should be able to seek a second opinion at any time of day or night. In her letter, which she published on Wednesday, Hughes also said the availability of that service must be widely advertised in hospitals, so patients know they can use it. She told Barclay that all staff in acute and specialist medical NHS trusts in England “must have 24/7 access to a rapid review from a critical care outreach team who they can contact should they have concerns about a patient”. Hughes added: “All patients, their families, carers and advocates must also have access to the same 24/7 rapid review from a critical care outreach team which they can contact via mechanisms advertised around the hospital and more widely if they are worried about the patient’s condition. This is Martha’s rule.” Read full story Source: The Guardian, 3 November 2023
  15. News Article
    A trust failed to identify risks associated with a helipad in one of its car parks, contributing to the death of an elderly woman who was blown over as a heavy search and rescue helicopter came into land. The Air Accident Investigations Branch found multiple factors contributed to 87-year-old Jean Langan’s death at Derriford Hospital in Plymouth in March 2022. Ms Langan was on her way to an appointment when she was blown over and another person seriously injured. Crispin Orr, chief inspector of air accidents, said: “Our in-depth investigation revealed systemic safety issues around the design and operation of hospital helicopter landing sites which need to be addressed at a national level.” Read full story (paywalled) Source: HSJ, 2 November 2023
  16. Content Article
    The Safe & Sound podcast by the Royal College of Surgeons in Ireland explores the world of human factors in healthcare and patient safety. Each episode, we will try to untangle different aspects of this complicated web of human factors in healthcare, through interviews with some extraordinary guests and faculty in Ireland, and across the world.
  17. Content Article
    A new guide to help health service trusts tackle racial discrimination in disciplinary procedures and promote inclusivity has been launched by NHS Providers.
  18. Content Article
    'Gridlock' of patients in urgent and emergency care is often attributed to a lack of onward capacity for people leaving hospital, leading to delayed discharges that back up the system. But does this explanation often favoured by government and policy makers tell the whole story? The Nuffield Trust's Quality Watch investigates whether the pattern is visible in patient journeys through urgent and emergency care at the integrated care system level.
  19. Content Article
    This study from Allan et al. investigates whether nurses working for a national medical telephone helpline show evidence of “decision fatigue,” as measured by a shift from effortful to easier and more conservative decisions as the time since their last rest break increases. The study found that for every consecutive call taken since last rest break, the odds of nurses making a conservative management decision (i.e., arranging for callers to see another health professional the same day) increased by 5.5% from immediately after 1 break to immediately before the next. Decision-making was not significantly related to general or cumulative workload (calls or time elapsed since start of shift). The authors concluded that every consecutive decision that nurses make since their last break produces a predictable shift toward more conservative, and less resource-efficient, decisions. Theoretical models of cognitive fatigue can elucidate how and why this shift occurs, helping to identify potentially modifiable determinants of patient care.
  20. News Article
    NHS England boss Amanda Pritchard has warned that meeting key elective recovery targets to eliminate 65-week waiters by March and ensure the waiting list is falling by next year is becoming “increasingly challenging”. Ms Pritchard also re-emphasised concerns already expressed by NHS England that “if strikes continue into winter, it will be extremely difficult for us to provide safe care to our patients, particularly with a twindemic of covid and flu”. The NHSE boss was asked by HSJ at the King’s Fund’s annual conference on Thursday how confident she was about the NHS achieving its next elective recovery target on 65-week waiters and the prime minister’s pledge in January to reduce overall waiting lists. Ms Pritchard said: “We are really encouraged that there are talks under way between the government and the British Medical Association but clearly having had the level of disruption over the last 10 months of industrial action, we have seen really significant challenge on maintaining focus on reducing both long waits and on tackling overall waiting list size.” She said that on weeks when there were no strikes, waiting lists reduced, and there had been sustained progress on cutting long waiters “despite the pressures of industrial action”. She praised the “extraordinary amount of focus and creativity from NHS staff” to achieve this. But she added: “[There has to be] a real recognition that with ongoing industrial action [reducing long waiters and the overall list] is going to be an increasingly challenging target.” Read full story Source: HSJ, 3 November 2023
  21. News Article
    A patient was left with permanent sight loss after a hospital failed to spot the signs of a blood vessel blockage for several months. The person referred to only as Mr L, visited the emergency department at one of Wales' hospitals in January, 2018, but medics failed to consider the possibility he had suffered a watershed stroke. Details of how it took nine months before Mr L was offered a scan to consider this diagnosis have been described in a report from the Public Service Ombudsman detailing the care under Betsi Cadwaldr University Health Board. The Ombudsman, Michelle Morris, also slammed the health board for its failure to act promptly with the complaints process. She said she "cannot fail to be shocked by the fact that, although Mr L first complained to the health board in June, 2019, it took until February, 2023 for it to recognise any failings." The report details how between January and September, 2018, the health board failed to promptly and appropriately identify, investigate and treat a blockage of blood vessels in his neck (a condition called carotid artery stenosis, where the blockage restricts the blood flow to the middle of the brain, face and head). Mr L also complained that when the issue was eventually identified in September, there was a delay in getting the treatment (surgery) until November. Read full story Source: Wales Online, 2 November 2023
  22. News Article
    NHS England is rolling out a national early-warning system to help medics spot and treat a deteriorating child patient quickly - and act on parents' concerns. Parents and carers are "at the heart of the new system", NHS chiefs say. Scores for signs such as blood pressure, heart rate and oxygen levels will be tracked on a chart. But if a parent is worried their child is sicker than the chart suggests, care will be rapidly escalated. While similar systems already exist in many hospitals, NHS national medical director, Prof Sir Stephen Powis, said staff and patients alike would welcome the introduction of a standardised system across hospitals. "We know that nobody can spot the signs of a child getting sicker better than their parents, which is why we have ensured that the concerns of families and carers are right at the heart of this new system, with immediate escalation in a child's care if they raise concerns and plans to incorporate the right to a second opinion as the system develops further," he said. The rollout follows the patient safety commissioner, Dr Henrietta Hughes, recommending that Martha's rule is delivered across England's hospitals, giving patients and families the right to an urgent second opinion and rapid review from a critical care team if they are worried about a patient's condition. Read full story Source: BBC News, 3 November 2023
  23. Content Article
    As clinicians, our primary objective is to provide the best possible care to our patients. In this pursuit, the administration of short-term intermittent IV antibiotics plays a crucial role in combating infections and saving lives; however, there is an under recognised issue, under delivery, that results in the misuse of antibiotics and could be exacerbating antimicrobial resistance. In this blog, Claire Davies, Clinical Therapy Manager at B. Braun Medical Ltd., explores the issue of under delivery and provides essential insights for clinicians to optimise their antibiotic therapy.
  24. Content Article
    As a patient receiving treatment for a bacterial infection through an IV administration set, commonly referred to as a drip, it’s essential to know that antibiotics play a crucial role in helping you get better. In this blog, Claire Davies, Clinical Therapy Manager at B. Braun Medical Ltd., explores an under-recognised issue that can affect your treatment, the unintentional under delivery of antibiotics via your drip. Claire explains why it’s important to ensure that all of your prescribed antibiotic dose is delivered via your drip and the measures being taken by healthcare providers to ensure that this happens.
  25. Content Article
    A new report from the Public Policy Projects (PPP) calls on integrated care systems (ICSs) to harness the unique capabilities of the pharmacy sector and implement a pharmacy-led transformation of healthcare delivery. The report, Driving true value from medicines and pharmacy, is chaired by Yousaf Ahmad, ICS Chief Pharmacist and Director of Medicines Optimisation at Frimley Health and Care Integrated Care System, and is the culmination of three roundtable events attended by key stakeholders from across the pharmacy sector and ICS leadership. Insight from these roundtables has also been accepted as evidence in the Health and Care Select Committee’s recent inquiry into the future of the pharmacy sector.
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