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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Carl Heneghan discusses the role of modelling in the Covid-19 pandemic.
  2. News Article
    Lessons still have not been learned at a Kent hospital trust which was criticised in a damning report, a mother has said. Dr Bill Kirkup's review found at least 45 babies might have survived with better care at East Kent NHS hospitals. Victoria, whose six-year-old daughter needs 24-hour support, said: "I've had no contact from anyone from the trust." Her case was one of 202 that were examined by Dr Kirkup in his report, which was published exactly a year ago. Victoria, whose daughter is living with the consequences of failings in her care during her birth, said: "Our children have become unwell because of what has happened to them. "I don't feel lessons have been learned whatsoever. "Treatment hadn't been made available as easily as it should have done for children that are still living this experience every day." Read full story Source: BBC News, 19 October 2023
  3. Event
    until
    Tackling health inequalities for children and young people has never been more important with NHS England’s Core20plus5 approach gives a clear steer on how to address these health inequalities from the top. As the health and care system continues to grapple with operational and strategic challenges, and there are increasing and competing pressures on the budgets of integrated care systems (ICSs). This King's Fund conference will take a solution-focused approach to explore how the health and care system can adapt to deliver meaningful change for children and young people, and how their voices and equitable resource allocation can take centre stage in decision-making. Register
  4. Content Article
    NHS colleagues are working hard to restore elective care, but data shows that activity for children and young people (CYP) is still below pre-pandemic levels and recovery remains behind rates seen in adult services. The specialties of ENT, dental services, ophthalmology, urology, and trauma and orthopaedics (including spinal surgery) are especially challenged, with the longest waiting lists for surgery for young patients. Getting It Right First Time (GIRFT) has supported NHS England’s drive for CYP elective recovery by developing concise guidance –Closing the gap: Actions to reduce waiting times for children and young people – offering ten actions which can help reduce waiting times for children, as well as quick links to data, resources and best practice case studies. The ten actions address how to improve theatre capacity, increase theatre utilisation and streamline pathways of care, and include practical measure such as adding extra sessions or ‘super events’ for children’s surgery, avoiding procedures of limited medical benefit by using clinical decision tools, and staggering children’s admission times. The guidance links to a series of case studies demonstrating how teams across England have taken innovative measures to address their waiting times.
  5. News Article
    Children are waiting years for autism and cerebral palsy treatments as NHS leaders accuse the government of ignoring warnings of a crisis in community care. The number of patients waiting for NHS community services hit more than one million in August and a new analysis has revealed one in five of those patients are children. The waits are so bad in some areas of England that a 12-year-old needing treatment might not get it until they are 16, the NHS Community Services Network warned. The analysis, by NHS Confederation and NHS Providers, also found 34,000 children have been waiting more than 18 weeks for diagnosis and care, which is the maximum time anyone should be waiting, with the backlogs growing quickly in spinal and eye care. Matthew Taylor, chief executive for NHS Confederation, which represents hospitals, community service providers and primary care, told The Independent that long waits can impact children more severely than adults because delays in treatment can have a knock-on effect on communication skills, social development and educational as well as mental wellbeing. “We have a real and growing problem with long waits in community services, but despite repeated warnings that neglect of these vital services is having a detrimental impact on patients, these warnings seem to be met with a shoulder shrug from the government. Leaders are working incredibly hard to deliver these important services for patients but are fighting a rising tide and need help,” he said. Read full story Source: The Independent, 20 October 2023
  6. News Article
    The boss of Britain’s biggest medicines courier has been told to urgently improve its complaints system by the NHS ombudsman amid concerns patients let down by missing deliveries are repeatedly ignored. In a highly unusual development, Darryn Gibson, the chief executive of Sciensus, has received a written warning from Rob Behrens, the parliamentary and health service ombudsman (PHSO). It says patients “should not be ignored” and must be “listened to and taken seriously” or he will consider taking further action. The PHSO investigates complaints that have not been resolved by the NHS or by private providers of NHS care. Sciensus is the single largest provider of homecare medicines services to the NHS and has contracts worth millions of pounds. In an email seen by the Guardian, Behrens told Gibson he had been unable to investigate most reports received about Sciensus because patients had not been able to complete the company’s complaints process. “That is not acceptable or fair to complainants,” Behrens wrote. In a statement, Sciensus said it worked “very hard” to ensure NHS patients received their medicines on time. Its services had “a 95% satisfaction rating”, it added. The move follows a Guardian investigation that exposed how Sciensus put NHS patients at risk of harm with delayed, missed or botched deliveries of medicines for conditions including cancer, heart disease, diabetes, dementia and HIV. It also uncovered how patients’ alarm at vital drugs and medical devices not arriving at their home was often compounded by a struggle to reach Sciensus to complain and fix the problems. Read full story Source: The Guardian, 19 October 2023
  7. News Article
    Almost two-thirds of maternity units provide dangerously substandard care that puts women and babies at risk, the NHS watchdog has said in a damning report. The Care Quality Commission (CQC) has rated 65% of maternity services in England as either “inadequate” or “requires improvement” for the safety of care – up from 54% last year. Services are beset by a host of problems, including serious staff shortages and internal tensions, which mean that too many mothers and their babies receive care that is not good enough, it said. Women too often face delays in accessing care, do not receive the one-to-one care from a midwife to which they are entitled or experience communication problems with staff looking after them, including being shouted at by midwives. The CQC judged overall quality of care to be inadequate or require improvement at 85 maternity units, almost as many at which it rated it to be either good or outstanding – 87. The number of units offering substandard care has soared by 30 in the last year, from 55 to 85. It said that, having inspected 73% of all maternity units, “the overarching picture is one of a service and staff under huge pressure. People have described staff going above and beyond for women and other people using maternity services and their families in the face of this pressure. “However, many are still not receiving the safe, high-quality care that they deserve.” Read full story Source: The Guardian, 20 October 2023
  8. Content Article
    The Care Quality Commission (CQC) State of Care is an annual assessment of health care and social care in England. The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve.
  9. Content Article
    Drawing on his research and practice, Steven Shorrock explores the various barriers that we face when trying to make sense of Just Culture, inviting readers to refl ect on the intricate nature of justice and safety in our complex world
  10. Content Article
    On 29 September 2023, a group of NHS staff and Experts by Experience joined a Teams meeting to help the National Patient Safety team in NHS England (NHSE) to answer two important questions. 1. Is it a good idea to keep asking NHS staff to record the level of psychological harm experienced by patients and service users, after a patient safety incident? 2. If so, how we can help make sure this is done as well and accurately as possible? Here is the write up of the workshop.
  11. News Article
    Children are not being over-diagnosed with ADHD despite concerns about a spike in prescriptions of powerful stimulant drugs, a leading psychiatrist has said. NHS statistics show 125,000 children and teenagers in England are taking drugs such as Ritalin for symptoms such as poor concentration, up by a quarter since before the Covid pandemic. Isobel Heyman, a consultant child and adolescent psychiatrist at Great Ormond Street Hospital and lead for child mental health at Cambridge Children’s Hospital, said that on the whole ADHD remained “under-treated” and that this was driving high levels of mental illness in young people. Speaking to the Times Health Commission, Heyman said: “My understanding is that the increase in prescribing is largely related to increased diagnosis and increased recognition … We are still overall slightly under-treating [rather] than over-treating. “There is a problem about over-medicalisation of ordinary distress, ordinary ebullience and over-enthusiasm in young people.” She said the public should be reassured that ADHD diagnoses follow a “very stringent” process. However, she said private adult ADHD clinics may be less “rigorous” in providing a diagnosis. Read full story (paywalled) Source: The Times, 18 October 2023 Further reading: Long waits for ADHD diagnosis and treatment are a patient safety issue
  12. News Article
    A hospital trust has dismissed three members of staff following complaints of sexual harassment. The sackings by University Hospitals Birmingham (UHB) NHS Trust were revealed at the launch of its sexual safety charter on Monday. Sexual safety was one of the areas highlighted in a review of the trust's culture. UHB said sexism, misogyny and sexual harassment would not be tolerated in the workplace. The trust has been subject to three enquiries following a BBC investigation into its culture. The second of these investigations, by Prof Mike Bewick, identified a new line of inquiry into allegations of misogynistic behaviour and sexual harassment. Prof Bewick said the trust had begun formal investigations and there was a widening of the scope of the enquiry to accommodate the sensitive nature of these concerns. Read full story Source: BBC News, 19 October 2023
  13. Content Article
    Healthcare is starting to embrace a shift towards Just Culture. In England, the new Patient Safety Incident Response Framework (PSIRF) prioritises respect, compassion, and systemic improvements. The potential benefits of this, and other initiatives, are significant, as Suzette Woodward reports
  14. Content Article
    The Patients Association spoke to Christiana Melam, Marie Adams and Susan Leach during Patient Partnership Week to talk about all things to do with social prescribing.  Christiana is the Chief Executive of the National Association of Link Workers, the UK's professional network for social prescribing link workers. She is an advocate for diversity, inclusion, coproduction, bottom-up approaches, social justice, empowering people and reducing inequality. Marie is a social prescriber, and Susan is a patient who has used social prescribing as part of her healthcare. Susan talked candidly about the relationship with Marie and how Marie has helped her cope with some serious challenges in her life. 
  15. Content Article
    Artificial intelligence, as a nonhuman entity, is increasingly used to inform, direct, or supplant nursing care and clinical decision-making. The boundaries between human- and nonhuman-driven nursing care are blurred with the advent of sensors, wearables, camera devices, and humanoid robots at such an accelerated pace that the critical evaluation of its influence on patient safety has not been fully assessed. Since the pivotal release of To Err is Human, patient safety is being challenged by the dynamic healthcare environment like never before, with nursing at a critical juncture to steer the course of artificial intelligence integration in clinical decision-making. This paper presents an overview of artificial intelligence and its application in healthcare and highlights the implications which affect nursing as a profession, including perspectives on nursing education and training recommendations. The legal and policy challenges which emerge when artificial intelligence influences the risk of clinical errors and safety issues are discussed.
  16. Content Article
    Alerts, recalls and safety information on medications from the Medicines and Healthcare products Regulatory Agency (MHRA)
  17. Content Article
    The Medicines and Healthcare products Regulatory Agency (MHRA) are providing an update on a retrospective observational study on the risk to children born to men who took valproate in the 3 months before conception and on the need for the re-analysis of the data from this study before conclusions can be drawn. No action is needed from patients.  For female patients, healthcare professionals should continue to follow the existing strict precautions related to preventing the use of valproate in pregnancy (Valproate Pregnancy Prevention Programme).
  18. Content Article
    The climate and ecological crises are both driven by human activities. They each have catastrophic implications for human health and their strong interconnection creates a vicious circle where each is reinforced by the other. A stable natural environment is critical for limiting global warming and achieving the UN’s Sustainable Development Goals (SDGs). Conversely, the loss of biodiversity is a major threat to human, animal, and environmental health. In order to mitigate harm and maximise the co-benefits of action, it is important that policies tackle both climate change and biodiversity loss together. This policy report by the UK Health Alliance on Climate Change, describes the impacts of biodiversity loss on land and oceans for human health and puts forward recommendations to reduce biodiversity loss, restore nature, and achieve climate goals for the benefit of health.
  19. Content Article
    The Medical Protection Society (MPS) is a member-owned, not-for-profit protection organisation for doctors, dentists and healthcare professionals. Here is there response to the Department of Health and Social Care consultation which introduces the regulation for Physician Associates (PAs) and Anaesthesia Associates (AAs).
  20. Content Article
    The number of older people having surgery is increasing. However, older patients are more likely to have complications after surgery than younger patients as they often have multiple health conditions and age-related problems such as frailty and a decline in mental ability. These factors increase the risk of surgery and can hinder recovery. Surgical pre-assessment usually focuses on the patient’s physical fitness for surgery, not the broader range of health-related factors that are important to consider in older patients. The Perioperative care for Older People undergoing Surgery (POPS) model was developed to provide a holistic assessment of an older person’s medical, physiological and functional condition prior to surgery. The assessment is then used to inform interventions that can reduce the risk of complications. The POPS model is increasingly being implemented across the English and Welsh NHS, but there are often challenges in introducing these new ways of providing care that need to be better understood. This independent study, led by THIS Institute Fellow Professor Justin Waring, outlines the key activities and strategies that are needed for the POPS model to be successfully implemented and become part of routine practice in a hospital.
  21. News Article
    A woman has spoken of her "complete shock" at being misdiagnosed with cancer and undergoing surgery when she never had the condition at all. Megan Royle, 33, from East Yorkshire, was diagnosed with skin cancer in 2019. As part of her treatment, she underwent immunotherapy and her eggs were frozen due to the risk to her fertility. But after she was given the all-clear in 2021, a review showed she never had cancer and she has now won compensation from the two NHS trusts involved. Ms Royle, from Beverley, said: "You just can't really believe something like this can happen, and still to this day I've not had an explanation as to how and why it happened. "I spent two years believing I had cancer, went through all the treatment, and then was told there had been no cancer at all." "You'd think the immediate emotion would be relief and, in some sense, it was - but I'd say the greater emotions were frustration and anger." Read full story Source: BBC News, 18 October 2023
  22. News Article
    Naga Munchetty has said she spent decades being failed, gaslit and “never taken seriously” by doctors, despite suffering debilitatingly heavy periods, repeated vomiting and pain so severe that she would lose consciousness. The BBC presenter, newsreader and journalist told the Commons women and equalities committee on Wednesday that she was “deemed normal” and told to “suck it up” by NHS GPs and doctors during the 35 years she sought help for her symptoms. Munchetty was finally diagnosed with adenomyosis, a condition where the lining of the womb starts growing into the muscle in its walls, in November last year. She said she was consistently told by doctors that “everyone goes through this”. “I was especially told this by male doctors who have never experienced a period but also by female doctors who hadn’t experienced period pain,” said Munchetty. Munchetty’s diagnosis came after she had bled heavily for two weeks and experienced pain so severe she asked her husband to call an ambulance. Only then was she taken seriously, seeing a GP who specialised in women’s reproductive health. That GP advised her to use private healthcare to avoid lengthy NHS waiting lists. Munchetty and Vicky Pattison, a television and media personality, were giving evidence as part of the committee’s inquiry into the challenges that women face being diagnosed and treated for gynaecological and reproductive conditions. The committee is also considering any disparities that exist in diagnosis and treatment, and the impact of women’s experiences on their health and lives. Read full story Source: The Guardian, 19 October 2023
  23. News Article
    Thousands of complaints made against nurses and midwives were rejected by the watchdog without investigation last year as it battles a huge backlog amid concerns rogue staff are being left unchecked. The Nursing and Midwifery Council has rejected hundreds more cases a year since 2018, including 339 where nurses faced a criminal charge, 18 for alleged sexual offences and 599 over allegations of violence in 2022-23, according to data shared exclusively with The Independent. The new figures come after The Independent revealed shocking allegations that nurses and midwives accused of serious sexual, physical and racial abuse are being allowed to keep working because whistleblowers are being ignored and that the NMC was failing to tackle internal reports of alleged racism. And now, a new internal document, obtained by The Independent, reveals more staff have come forward to raise concerns since our expose. Former Victims’ Commissioner Dame Vera Baird KC said the backlog of complaints was “worryingly high” and called for urgent action to tackle it. Read full story Source: The Independent, 19 October 2023
  24. News Article
    Over the counter genetic tests in the UK that assess the risk of cancer or heart problems fail to identify 89% of those in danger of getting killer diseases, a new study has found. Polygenic risk scores are so unreliable that they also wrongly tell one in 20 people who receive them they will develop a major illness, even though they do not go on to do so. That is the conclusion of an in-depth review of the performance of polygenic risk scores, which underpin tests on which consumers spend hundreds of pounds. The findings come amid a boom in the number of companies offering polygenic risk score tests which purport to tell customers how likely they are to get a particular disease. Academics at University College London (UCL) who undertook the research are warning that such tests are so flawed they should be regulated “to protect the public from unrealistic expectations” that they will correctly identify their risk of a particular disease. The authors concluded: “Polygenic risk scores performed poorly in population screening, individual risk prediction and population risk stratification. “Strong claims about the effect of polygenic risk scores on healthcare seem to be disproportionate to their performance.” Read full story Source: The Guardian, 17 October 2023
  25. News Article
    A locum responsible pharmacist has been issued a warning after a patient died when he dispensed the wrong strength of oxycodone during a staffing crunch, the regulator has revealed. Paresh Gordhanbhai Patel supplied 120mg rather than the prescribed 20mg of oxycodone hydrochloride to an “elderly” patient while working two locum shifts as responsible pharmacist at Crompton Pharmacy at Whitley House Surgery in Chelmsford. After taking one tablet, the patient died from an “accidental” oxycodone “overdose”, the General Pharmaceutical Council’s (GPhC) fitness-to-practise (FtP) committee heard at a hearing held on 11-13 September. Mr Patel admitted that he was “stressed and overtired” when he failed to notice a “discrepancy” between the prescribed strength of oxycodone and what he ordered and dispensed, The regulator heard that Mr Patel was “over-conscientious” and felt compelled “at a human level” to help out at the under-staffed pharmacy, despite the fact that it was “not safe to do so”, it added. Mr Patel admitted that his errors “amounted to misconduct” and conceded to the committee that his fitness to practise was “impaired” because he “breached one of the fundamental principles of the pharmacy profession.” The regulator heard that Mr Patel had “immediately” admitted his mistake to the pharmacy and did so again at the coroner’s inquest, where he also publicly apologised to the patient’s family. Read full story Source: Chemist and Druggist, 12 October 2023
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