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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Sussex Community NHS Foundation Trust share their patient safety newsletters with the hub.
  2. News Article
    The NHS requires a ‘new central investment’ to achieve digital maturity and realise the potential of emerging technologies, according to the person who was commissioned by Jeremy Hunt to examine the issue in 2015. Bob Wachter was commissioned by the then health and social care secretary in 2015, and authored the 2016 report Making IT Work, which called on all NHS trusts to achieve the “realistic target” of a good level of digital maturity by 2023. While Professor Wachter told HSJ that there had been “reasonably good” progress, he said it was “not quite what I would have hoped for” seven years on from his report. He acknowledged that factors such as the pandemic and the subsequent economic situation slowed progress, but added that he was “a little bit worried” at the state of digital maturity in some areas, including interoperability and reliability of key systems such as electronic patient records. Read full story (paywalled) Source: HSJ, 1 November 2023
  3. News Article
    Are you a patient whose experience has led you to develop a healthcare innovation? Do you want to develop your skills to help scale this innovation? The NHS Clinical Entrepreneur Programme (CEP) is offering a 12-month pilot programme for people who have experience of a long-term health condition and are working on healthcare innovations. The NHS CEP Patient Entrepreneur Programme, ran by Anglia Ruskin University and in collaboration with NHS England’s Patient and Public Involvement (PPI) team, is free, part-time, and open to all patients, or carers with an innovation in healthcare. The programme aims to give individuals the skills and knowledge to develop their innovation, while giving them access to a network of mentors, healthcare experts, and patient support. Applications for this programme will open on the 1 November 2023, with the programme starting March 2024. So, if you are a patient with lived experience of an illness or condition who has developed an innovation to improve patient care, this is your chance to scale your idea with the help of the NHS Clinical Entrepreneur Programme. Find out more
  4. Content Article
    This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 27 October 2023. At this meeting, members of the network were joined by Dr Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB). The PSMN, created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. It provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out more about the Network.
  5. Content Article
    Healthcare Organisational Culture (OC) is a major contributing factor in serious failings in healthcare delivery. Despite an increased awareness of the impact that OC is having on patient care, there is no universally accepted way to measure culture in practice. This study from Simpson et al. was undertaken to provide a snapshot as to how the NHS is currently measuring culture. Although the study is based in England, the findings have potential to influence the measurement of healthcare OC internationally.
  6. Content Article
    Roger Kline is a research fellow at Middlesex University Business School prior to which he held senior positions in eight UK trade unions. Roger has an extensive knowledge and experience of workplace culture, primarily in the public sector. On his web page you can find a selection of his published papers, books and blogs.
  7. Content Article
    The aim of this investigation and report is to help improve the inpatient care of adults with a known learning disability in acute hospital settings. It focuses on people referred urgently for hospital admission from a community setting, such as a person’s home or residential home. In undertaking this investigation, the Health Services Safety Investigations Body (HSSIB) looked to explore the factors affecting: The sharing of information about people with a learning disability and their reasonable adjustment needs following admission to an acute hospital. How ward-base staff are supported to delivery person-centred care to people with a learning disability.
  8. News Article
    Children feel they have to attempt suicide multiple times before they get treatment from NHS mental health services, the former children’s commissioner has warned. Anne Longfield said that schoolchildren were aware that NHS mental health infrastructure was “buckling and far from being able to cope with the demand”. She told the Times Health Commission: “When I first became children’s commissioner in 2015, the thing that children talked about most often was mental health. They said they knew they couldn’t get help and treatment easily, because there just wasn’t enough help to go around. “Some said, we know that we’ve almost got to try and take our own life before we can get help. And I thought that was pretty shocking at the time. Now, young people are saying not only do they have to try to take their own life, they have to try and take their own life several times, and they say there will be an assessment of levels of intent within that.” Read full story Source: The Times, 1 November 2023
  9. News Article
    Nearly four years since the start of the coronavirus outbreak, you could be forgiven for believing the pandemic is behind us. But for many, it feels far from over. Close to two million people face a daily battle with debilitating symptoms of Long Covid – the lasting symptoms of the virus that remain after the infection is gone – with some now housebound, unable to walk and even partially blind. Alan Chambers, 49, is among those who have been grappling with the illness for years, having caught coronavirus in March 2020. Mr Chambers went from being “a fit, healthy, working member of the community who would do anything to help anyone” to being “ill and isolated in our bedroom”, blind in one eye and no longer able to walk unaided, his wife Vicki said. As of March, an estimated 1.9 million people in the UK have experienced coronavirus symptoms for more than four weeks, according to the latest figures from the Office for National Statistics. Of those, 1.5 million reported the condition had adversely affected their day-to-day activities. It comes as coronavirus case rates have shown an overall increase since July, with fears the approaching winter will bring a further surge in infections. Yet in May, the World Health Organisation (WHO) declared that coronavirus no longer represents a global health emergency, which was seen as a symbolic step towards the end of the pandemic. Dr Jo House, founding member and health advocacy lead at Long Covid Support, said the advocacy group now has 62,000 members, with about 250 more people joining every month. “In their words, they feel ‘forgotten, unheard, disbelieved, isolated, unemployed, disabled, immobile’. NHS England admitted to The Independent that access to necessary support, treatment and care for Long Covid patients is still lacking. It said there was “still more to do to ensure support is there for everyone who needs it”, so that patients requiring specialist assessment and treatment for Long Covid can access care in a timely way. Read full story Source: The Independent, 29 November 2023
  10. News Article
    Millions of patients will be handed the power to view their own medical records and test results online after the NHS overruled opposition from the doctors’ union. From 1 November every GP surgery in England will be contractually obliged to give all patients over the age of 16 access to their health information on their phones. It means patients will no longer have to ring up their surgery or book a GP appointment to get details of blood test results, medications and repeat prescriptions, but instead they can access them by logging in to the NHS app. The British Medical Association (BMA) had threatened to go to court over the plans, arguing that granting people access to their records would add to GP workloads and could put patients at risk. However, Jacob Lant, the chief executive of the charity umbrella group National Voices, said: “Ensuring everyone has access to their own medical records through the NHS app is an important step in building a more equal partnership between patients and clinicians. “It gives people much easier access to the information they need to prepare for appointments, and having quick access to test results can help patients manage their conditions better. Using technology in this way has the potential to help millions, and free up capacity of staff to help those who are less able to make use of digital services.” Read full story (paywalled) Source: The Times, 31 October 2023
  11. Event
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    This online panel discussion brings together researchers, healthcare professionals, people living with mesothelioma and their families for open conversations about palliative care. Palliative care has the potential to increase the wellbeing of both people with incurable conditions and their families, yet some are reluctant to engage with this care. Drawing on expertise and first-hand experiences, the event will explore questions such as: what is palliative care? How can it help both people living with health conditions and their families? What are the common misunderstandings around palliative care, and what is the reality? Whilst this can be a difficult topic we hope, through shared experiences and by uncovering misunderstanding, to explore how palliative care has the potential to help us all. Led by the Mesothelioma UK Research Centre, University of Sheffield. Register
  12. News Article
    The government must allow health systems to plan their finances over a longer period to help deliver ‘real’ savings by rationalising services, says a leading chief executive. Kevin McGee, who recently stepped down from Lancashire Teaching Hospitals, said the “short-termism” baked into the annual NHS budget cycle is a major source of frustration for local leaders. Many trusts and systems have struggled to deliver their financial plans this year due to the savings required, and Mr McGee warned that continuing to “salami slice” the budgets will exacerbate patient safety risks. He said Lancashire and many other systems urgently need to rationalise and consolidate acute services on fewer sites, which would bring significant cost savings. However, changes such as these can often take years to plan and implement. Read full story (paywalled) Source: HSJ, 1 November 2023
  13. News Article
    Black, Asian and minority ethnic people experience longer waiting times, and are less likely to be in recovery after treatment, when accessing NHS mental health services compared with their white counterparts, a report has found. The research looked at 10 years’ worth of anonymised patient data from NHS Talking Therapies, formerly known as Improving Access to Psychological Therapies – an NHS programme that launched in 2008 to improve patient access to NHS mental health services. A total of 1.2 million people accessed NHS Talking Therapies services in 2021-22, and by 2024 the programme aims to help 1.9 million people in England with anxiety or depression to access treatment. The report, Ethnic Inequalities in Improving Access to Psychological Therapies, commissioned by the NHS Race and Health Observatory and undertaken by the National Collaborating Centre for Mental Health, found that people from black and minority ethnic backgrounds were less likely to go on to have at least one treatment session, despite having been referred by their GP, than their white counterparts. Dr Lade Smith, the president of the Royal College of Psychiatrists, said: “For far too long we have known that people from minoritised ethnic groups don’t get the mental healthcare they need. This review confirms, despite some improvements, it remains that access, experience and outcomes of talking therapies absolutely must get better, especially for Bangladeshi people. “There is progress, particularly for people from black African backgrounds, if they can get into therapy, but getting therapy in the first place continues to be difficult. This review provides clear recommendations about how to build on the improvements seen. I hope that decision-makers, system leaders and practitioners will act on these findings.” Read full story Source: The Guardian, 1 November 2023
  14. Content Article
    An independent review from the NHS Race & Health Observatory of services provided by NHS Talking Therapies has identified that psychotherapy services need better tailoring to meet the needs of Black and minoritised ethnic groups.
  15. Content Article
    In late 2015, the National Advisory Group on Health Information Technology in England was formed to advise the Department of Health and NHS England on its efforts to digitise the secondary care system. Our recommendations fall into two broad categories: 10 overall findings and principles, followed by 10 implementation recommendations.
  16. Content Article
    A damning report from the UK’s parliamentary and health service ombudsman recently published highlights sepsis deaths that he believes could have been prevented. The past decade has seen several campaigns to raise awareness of sepsis, but serious failings are still occurring, reports Jacqui Wise in this BMJ analysis.
  17. News Article
    People have been hospitalised after taking a fake version of the weight-loss control jab Ozempic, with 369 drugs seized by the UK’s medicines safety regulator. The fake jabs, obtained without prescription through black market suppliers, were seized by the Medicines and Healthcare Products Regulatory Agency. Ozempic, the brand name for semaglutide, and demand for the medicine has contributed to shortages in the product, which is also used for people with type 2 diabetes. The watchdog said a low number of patients had been hospitalised and reported serious side effects, including hypoglycaemic shock. Others ended up in a coma, which indicates the pens may have contained insulin rather than semaglutide. It has urged the public not to buy drugs without a prescription and warned buying prescription-only medicines online “poses a direct danger to health”. Read full story Source: The Independent, 29 October 2023
  18. News Article
    Patients who have been waiting more than 40 weeks for treatment in England will be offered the option of getting seen in another part of the country. About 400,000 will be contacted in the coming weeks and asked whether they would be willing to travel and how far. Patients already have a right to ask for treatment elsewhere. But NHS England believes that by proactively contacting the longest waiters they will help unlock some of the worst bottlenecks in the system. Only those who do not have an appointment already scheduled within the next eight weeks will receive the offer via text, email or letter. The 400,000 figure represents about 5% of the total number waiting for treatment. If a patient is happy to travel, the treatment could either be in an NHS or private sector hospital. Those on low incomes will be entitled to some financial support to enable them to travel for treatment. Patients will retain their place on the waiting list at their local hospital while other options are explored. Read full story Source: BBC News, 31 October 2023
  19. News Article
    Parents of babies who have died or been harmed as a result of poor care are demanding that ministers order a public inquiry into repeated failings in NHS maternity units. They want Steve Barclay, the health secretary, to set up a judge-led statutory inquiry to investigate recurring problems in maternity services, which cost the NHS in England £2.6bn a year in damages. Babies are still being damaged and dying, despite previous inquiries into maternity scandals at the Morecambe Bay, Shrewsbury and Telford, and East Kent NHS trusts recommending changes. The NHS’s failure to improve maternity safety is so alarming that a public inquiry is needed to finally ensure that women and babies no longer come to harm, the families say. The Maternity Safety Alliance, a group of relatives of newborns who have died due to lapses in NHS childbirth, warned that scandals will continue unless such an inquiry is held. “Our babies are too precious to keep on ignoring the reality that despite a raft of national initiatives and policies implemented in the wake of investigations and reports, systemic issues continue to adversely impact on the care of women and babies. “Far too much avoidable harm continues to devastate lives in circumstances that could and should be avoided. Fundamental reform is needed,” they said in a letter urging Barclay to intervene. Read full story Source: The Guardian, 31 October 2023
  20. Content Article
    Changes of all kinds can have a profound effect on us, both in terms of our wellbeing and performance. David Murphy has worked therapeutically with people, including front-line professionals, for over 20 years, helping them to change, and adapt to change. David talks to Steven Shorrock about dealing with traumatic events and more mundane changes.
  21. Content Article
    Simulations are routinely used to identify latent safety threats. This article describes the classification of 1,318 latent safety threats identified from 232 simulations. Researchers were then able to issue site-specific and organisation-wide standardised dashboards and summaries, thus allowing for local and systemwide improvements.
  22. Content Article
    The Children and Young People’s Mental Health Coalition (CYPMHC) and the Maternal Mental Health Alliance have launched ‘The Maternal Mental Health Experiences of Young Mums’ report, which includes both a literature review and first-hand insights from young mums impacted by maternal mental health problems.
  23. News Article
    Lawyers for a doctor at the centre of Northern Ireland's biggest patient recall have withdrawn from his new fitness to practise hearing. Legal representatives for Michael Watt said they are "concerned about his serious mental health condition". They told the Medical Practice Tribunal Service that the continuation of the hearing in public "presents a real risk to his mental health". A new fitness to practise hearing began in September. The legal team has also formally withdrawn an application to the tribunal for Michael Watt to remove himself from the medical register. It followed a ruling by the High Court earlier this year to quash a decision where he previously was voluntary erased from the medical register. The tribunal is inquiring into the allegation that, between 7 and 22 of October 2018, Michael Watt underwent a General Medical Council assessment of the standard of his professional performance. It is alleged that that performance was unacceptable in the areas of maintaining professional performance, assessment, clinical management, record keeping and relationship with patients. Read full story Source: BBC News, 27 October 2023
  24. Content Article
    New analysis by the Health Foundation shows that, if current trends continue, the waiting list for routine hospital treatment (‘elective care’) in England could rise to over 8 million by next summer, regardless of whether NHS industrial action continues.   The analysis models four different future scenarios to look at the prospects for reducing the waiting list by the end of 2024. It shows that, on current trends, the waiting list could peak at 8 million by August 2024 if there is no further strike action, before starting to fall. If strike action were to continue the waiting list could be 180,000 higher.   The analysis finds that industrial action by consultants and junior doctors has so far lengthened the waiting list by around 210,000, just 3% of the overall size of the list, which totalled 7.75 million at the end of August 2023. The analysis also points out that strikes are also likely to have indirect impacts, by squeezing NHS finances and diverting management attention away from productivity improvement.    The analysis, which features an interactive ‘waiting list calculator’, also includes illustrative better and worse case scenarios.
  25. Content Article
    Since the 2007 landmark report on Preventing Medication Errors from the US National Academy of Medicine, effective interventions have been developed to address medication errors. Despite this, medication errors persist as the most common source of harm for patients worldwide. In this Editorial, Albert Wu looks at whether WHO's “The 5 Moments for Medication Safety” as a patient engagement tool has reached its intended audience.
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