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Patient Safety Learning

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  1. Content Article
    Those who work in health and care are keenly aware of the need to identify and manage risks to protect patients from harm. But we are not the only industry that must take safety seriously. This video from the Healthcare Services Safety Investigation Branch (HSSIB) we compare notes with other safety-conscious industries – oil and gas, shipping, aviation, rail, road, nuclear and NASA – to understand their approach to safety management. In these fields, systems for organising and coordinating safety are often called Safety Management Systems (SMSs). See also HSSIB's report: Safety management systems: an introduction for healthcare.
  2. News Article
    At least two trusts are set to fall short on a high-profile pledge to eradicate ‘dormitory’ style wards in mental health facilities, with delays caused by cost pressures and shortage of materials and labour. In 2020, ministers said more than 1,200 beds in mental health dormitories across more than 50 sites would be replaced with single, en-suite accommodation by March 2025. Around £400m was allocated to achieve this. However, information gathered by HSJ via freedom of information requests suggests there will be at least 37 dormitory beds still in use beyond that date. In 2018, the Care Quality Commission said: “In the 21st century, patients, many of whom have not agreed to admission, should not be expected to share sleeping accommodation with strangers, some of whom may be agitated”. Patients have told HSJ they felt “distressed”, “unsafe” and “intimidated” on dormitory style wards. Leaders of trusts impacted by delays told HSJ of rising cost pressures, shortages of construction materials and availability of labour. Read full story (paywalled) Source: HSJ, 17 October 2023
  3. News Article
    Stroke patients should be offered extra rehabilitation on the NHS, say updated guidelines for England and Wales. The National Institute for Health and Care Excellence (NICE) had previously recommended 45 minutes a day. But it believes some patients may need more intensive therapy for recovery and is suggesting three hours a day, five days a week. Experts welcome the advice, but question how feasible it will be for a stretched health service to deliver. NICE accepts it may be "challenging", but it says patients and families deserve the best care possible. That includes help regaining speech, movement and other functions caused by the damage that happens to the brain during a stroke. NHS England has said increasing the availability of high quality rehabilitation is a priority. More people than ever are surviving a stroke thanks to improvements in NHS care, it added. Read full story Source: BBC News,18 October 2023
  4. Content Article
    Safety Management Systems (SMSs) are an organised approach to managing safety which are widely used in different industries. In this report, the Health Services Safety Investigations Body (HSSIB) identifies the requirements for effective SMSs, how these are used in other safety-critical industries and considers the potential of application of this approach in healthcare. It makes safety recommendations for NHS England and the Care Quality Commission in relation to this. See also HSSIB's video Introduction to safety management systems.
  5. News Article
    Britain’s top family doctor is calling for a “black alert” system to be introduced in general practice so that doctors can warn when surgeries are dangerously over capacity. It comes as a report reveals that almost half of GPs can no longer guarantee safe care for millions of patients, as a shortage of medics means they are unable to cope with soaring demand. Prof Kamila Hawthorne, the chair of the Royal College of General Practitioners (RCGP), which represents 54,000 family doctors across the UK, wants a patient safety alert system introduced that is modelled on the operational pressures escalation levels (Opel) warnings – known as “black alerts” – already used by hospitals. It would enable practices and GPs to flag unsafe levels of workload, triggering support from their local health system. GP surgeries would be able to temporarily suspend non-priority activities – including some regular health checkups, certain routine but mandatory staff training and non-urgent paperwork – during periods of excessive workload. This would allow surgeries to reprioritise routine and non-urgent activity and ensure patient safety is prioritised. Hawthorne said: “General practice is a safety-critical industry yet GPs have none of the mechanisms that other safety-critical professions, such as the air traffic industry, have in place to protect them. “Our number one priority is the safety of our patients, but GPs are doing more and more to try to meet the rising demand for our services. When you’re fatigued, you’re more likely to make mistakes and our survey shows that many GPs are no longer able to guarantee that the care they are providing to their patients is as safe as it could be.” Read full story Source: The Guardian, 17 October 2023
  6. News Article
    High use of agency staff contributed to the care failings exposed at a mental health trust by undercover reporters, an internal inquiry has found. Essex Partnership University Trust was at the centre of a Channel 4 documentary last year which raised concerns over care, including the use of restraints and patient observations. The trust initially refused to release the final report after a freedom of information request by HSJ, but has now released a redacted version on appeal. The report identified a number of concerns in relation to patient and staff safety, saying factors that contributed to these concerns included high usage of temporary staff and high patient acuity on the two acute mental health wards recorded. The internal inquiry looked into allegations of the inappropriate use of restraints raised in the documentary. This section, which contained redactions, found restraint was taught to be used as a last resort, but suggested high temporary staffing levels and a “lack of confident and adequately skilled staff” contributed to guidance not being followed. Another concern was around staff sleeping on duty and the use of mobile phones during patient observations. The internal inquiry found there was an “absence of visible leadership and role modelling” to ensure this did not happen during clinical practice. Read full story (paywalled) Source: HSJ, 17 October 2023
  7. News Article
    Health advocates in the USA are calling on the Biden administration to declare a public health emergency over a steep rise in congenital syphilis cases. The easily treated infection has quintupled in 10 years and can have harrowing impacts on children. Congenital syphilis happens when a baby contracts syphilis from its mother. Up to 40% of babies born to untreated mothers will be stillborn or die. Others can be left with severe birth defects such as bone damage, anaemia, blindness or deafness, and “neurological devastation”. “There is not a single baby that should be born in the US with syphilis,” David Harvey, the executive director of the National Coalition of STD Directors, told the Guardian. “We will be judged very severely as a country and a society for allowing this to happen to babies, when it is so easy to diagnose, treat and prevent this disease.” Rates of the disease have reached a nearly 30-year high just as supplies of the preferred medication, called Bicillin L-A, are in short supply. Syphilis can be cured with between one and three shots of the medication. Pfizer is the only manufacturer of the medication, a form of the first antibiotic ever synthesized, penicillin. The company said it does not expect shortages to be resolved before 2024, and blamed low supply partly on the increase in syphilis cases. Read full story Source: The Guardian, 17 October 2023
  8. News Article
    ChatGPT , the artificial intelligence tool, may be better than a doctor at following recognised treatment standards for depression, and without the gender or social class biases sometimes seen in the physician-patient relationship, a study suggests. The findings were published in Family Medicine and Community Health. The researchers said further work was needed to examine the risks and ethical issues arising from AI’s use. Globally, an estimated 5% of adults have depression, according to the World Health Organization. Many turn first to their GP for help. Recommended treatment should largely be guided by evidence-based clinical guidelines in line with the severity of the depression. ChatGPT has the potential to offer fast, objective, data-based insights that can supplement traditional diagnostic methods as well as providing confidentiality and anonymity, according to researchers from Israel and the UK. Read full story Source: The Guardian, 16 October 2023
  9. Content Article
    Extravasation is the leakage of intravenously administered solution into surrounding tissues, which can cause serious damage to the patient. There are multiple guidelines and local policies relating to extravasation injuries but not a singular national uniform policy.  NHS Resolution share their recent slides on what can be learned from extravasation claims, presented at the IV Therapy Summit.
  10. Content Article
    When a patient is deteriorating but no one is listening, Martha’s rule will guarantee a second opinion. Martha’s mother, Merope Mills, calls for doctors and nurses to embrace its implementation.
  11. Content Article
    This report provides a comprehensive analysis of the adult social care workforce in England and the characteristics of the 1.52 million people working in it. Topics covered include: recent trends in workforce supply and demand, employment overview, recruitment and retention, demographics, pay, qualification rates, and future workforce projections.
  12. Content Article
    NHS England provides regular updates on progress with the implementation of the Digital Clinical Safety Strategy to show how they've captures insights about digital clinical safety, how they are training their workforce to support safety in this area and how they use technology to drive safer care.
  13. News Article
    An ambulance trust has apologised after a patient who was declared "dead" later woke up in hospital. As first reported by The Northern Echo, the individual was taken by paramedics to Darlington Memorial Hospital on Friday. The newspaper reported they had been declared dead following an incident earlier that day. The North East Ambulance Service (NEAS) apologised to the patient's family and said an inquiry had begun. The patient has not been identified or their current condition revealed. NEAS director of paramedicine Andrew Hodge said: "As soon as we were made aware of this incident, we opened an investigation and contacted the patient's family. "We are deeply sorry for the distress that this has caused them. "A full review of this incident is being undertaken and we are unable to comment any further at this stage. "The colleagues involved are being supported appropriately and we will not be commenting further about any individuals at this point." Read full story Source: BBC News, 17 October 2023
  14. News Article
    An employment and equality lawyer will lead investigations into claims of racism, sexism and toxic culture at the Nursing and Midwifery Council (NMC). The nursing regulator has appointed Ijeoma Omambala KC to review claims that fitness to practise cases have been mishandled, especially those involving racism, discrimination, sexual misconduct and child protection. She will lead a concurrent investigation into how complaints about allegations were handled. "I’m sorry anyone has concerns about our culture, and the regulatory decisions we take. We’re committed to a rigorous, transparent and independent response". Read full story (paywalled) Source: Nursing Standard, 17 October 2023
  15. News Article
    The government ignored expert warnings to regulate physician associates (PAs) for more than two decades and now patients have come to harm, doctors have said. A leading doctors’ union blamed the “dithering of successive governments” for the “extremely dangerous” increase in PAs carrying out doctors’ duties. Jeremy Hunt, then health secretary, told a House of Lords committee in 2016 that the government was “committed to introducing legislation for regulatory reform” and it was “a question of finding a parliamentary slot”, citing Brexit debates as a cause of the delay. Seven years, two consultations and at least two deaths later, regulation of PAs is still a year away, following a series of delays that the Faculty of Physician Associates itself has called “disappointing”. Dr Matt Kneale, co-chair of the Doctors’ Association UK, told The Telegraph the lack of regulation “poses a significant risk to both patient safety and the overall standard of care within the NHS”. He said supervising doctors taking on the accountability for PA was not a “tenable long-term solution”. “Regulation could and should have been introduced earlier to prevent instances of patient harm. The lack of action for over two decades is concerning and requires urgent action,” he added. Read full story (paywalled) Source: The Telegraph, 14 October 2023
  16. News Article
    A primary school teaching assistant died from a stroke after hospital staff told her family that the life-saving treatment she needed was not available at weekends. Jasbir Pahal, 44, who had four children and was known as Jas, died in November last year after suffering a stroke. Her family was told she could only be treated with aspirin because a procedure to remove the blood clot was only available from 8am to 3pm, Monday to Friday. It has now emerged that the life-saving treatment, called mechanical thrombectomy, was available at an NHS hospital trust just a 40-minute drive away from the Calderdale Royal hospital in Halifax where she was being treated, but there were no arrangements for such transfers. Jasbir’s husband, Satinder Pahal, 49, said: “We have paid the ultimate price for this deficient service. Despite our pleas to save Jas’s life, all they could do was to give her an aspirin. “My wife was a vegetarian, never drank alcohol or smoked. She was fit and healthy and she wasn’t given the chance to survive. Jas was the centre of our worlds and her loss will impact us for ever.” The family are calling for urgent action to prevent future deaths." The Observer reported last month of warnings by the Stroke Association charity and clinicians about the regional variations in access to mechanical thrombectomy. It has been described as a “miracle” treatment, with some patients who were at risk of death or permanent disability walking out of hospital the day after the procedure. Read full story Source: The Guardian, 15 October 2023
  17. News Article
    Most trusts are thought to have missed the deadline to launch a new national incident reporting system that has already been beset with difficulties and delays. Seventy per cent of more than 150 patient safety managers polled during a patient safety management network meeting last month said their organisation would not meet the 30 September go-live deadline for the new learning from patient safety events (LFPSE) incident reporting system. LFPSE is a key part of NHS England’s safety strategy and replaces the historic national reporting and learning system. The new reporting system was originally due to be implemented by March 2023. However, this deadline was pushed back six months, after widespread concerns were raised by patient safety managers, which included software quality, incident reporting form complexity and lack of time for testing. Managers have pinned the latest launch delay on RLDatix – the vendor which provides incident software for more than 60% of trusts – claiming it could not provide the functionality needed and its releases were “not fit for purpose”. Read full story (paywalled) Source: HSJ, 16 October 2023
  18. News Article
    Trusts haven been warned to be careful of “contentious” approaches to staff recognition, such as those that mimic the “clap for carers” initiative organised during the pandemic. NHS England has published a Staff Recognition Framework which stresses marking staff achievements is important. However, it also warns staff could also be demoralised by recognition they felt was derisory. The framework says: ”During the pandemic, studies suggested the weekly 8pm ‘clap for carers’ movement and use of the word ‘heroes’ were contentious approaches to staff recognition. The NHS is always in the media spotlight. Don’t let this put you off but do consider the broader political and economic context.” Recent strikes saw clinicians make the point that organised clapping was no substitute for increase-linked pay increases. The document for senior leaders recommends “developing a recognition strategy” which takes a triple track “formal, informal and everyday” approach to celebrating staff achievement. It said “evidence shows that pay alone will not influence staff wellbeing, engagement, and retention in the long-term – praise and social approval have also proved to be critical factors”. Read full story (paywalled) Source: HSJ, 12 October 2023
  19. News Article
    A mother’s claim that a hospital failed to provide suitable experts for a coroner to determine the cause of her daughter’s death could lead to a second inquest. The attorney-general has acknowledged in a letter to the mother of Gaia Young that although the facts of the case did not suggest that NHS officials had been in contempt of court they “may amount to a reason to seek a fresh inquest”. The dispute centres on the circumstances of the death of Gaia Young, 25, who died at University College Hospital, London, in 2021 after being admitted for a sudden headache and vomiting, having spent the day cycling. At her inquest in February 2022 the coroner gave a narrative ruling, stating that “a missed chance” by doctors when she arrived at the hospital led to her death, concluding that the cause of death was unclear. Her mother, Lady Dorit Young, has argued that doctors misread her daughter’s condition and failed to treat her appropriately as she deteriorated. Young told the inquest that the hospital sent a doctor to the hearing to give evidence who was insufficiently skilled to assist the coroner, and that the hospital had more suitably qualified experts available. In the letter, Young said a court had ordered the hospital to “ensure the attendance at the inquest of such medical witness or witnesses to give oral evidence as are best able to assist [the coroner] with the likely cause of the deceased’s cerebral oedema and thus her death”. Lady Young believes that her daughter died from a metabolic encephalopathy — a brain injury — and asked for a neurological specialist to attend the inquest. She said the expert who attended was “not appropriately qualified or experienced” and that the inquest “was uninformed and uninformative: a waste of time and money”. Truth For Gaia provides open access to coroner’s inquest papers, transcript, medical records and post-mortem reports. Source: The Times, 16 November 2023
  20. Content Article
    The Covid-19 pandemic resulted in major disruption to healthcare delivery worldwide causing medical services to adapt their standard practices. Learning how these adaptations result in unintended patient harm is essential to mitigate against future incidents. Incident reporting and learning system data can be used to identify areas to improve patient safety. A classification system is required to make sense of such data to identify learning and priorities for further in-depth investigation. The Patient Safety (PISA) classification system was created for this purpose, but it is not known if classification systems are sufficient to capture novel safety concepts arising from crises like the pandemic. This study from Purchase et al. aimed to review the application of the PISA classification system during the COVID-19 pandemic to appraise whether modifications were required to maintain its meaningful use for the pandemic context. The study found that PISA taxonomy can be successfully applied to patient safety incident reports to support the first stages in deriving learning and identifying areas for further enquiry. No incidents were identified that warranted new codes to be added to the PISA classification system, which may extend to other substantive public health crises, negating the need for additional, specific coding within such classification systems and related frameworks for similar system-wide constraints.
  21. Content Article
    The Community Hospitals Association (CHA) has designed a suite of resource packs as a way of sharing some of the learning in an accessible way. This resource pack focuses on the topic of safer staffing in community hospitals. This resource pack has been compiled because of requests from members of the CHA and the Special Interest Group in Q
  22. Content Article
    Recognition is about thanking people for their contribution at work. It is embedded in the organisational values of the NHS. By improving recognition we can deliver the NHS Long Term Workforce Plan’s ambition to attract and retain the workforce we need to deliver improved patient care. One of the seven elements of the NHS People Promise is, ‘we are recognised and rewarded’. It defines recognition as: “A simple thank you for our day-to-day work, formal recognition for our dedication…” It is important that we recognise our staff because evidence shows that pay alone will not influence staff wellbeing, engagement, and retention in the long-term – praise and social approval have also proved to be critical factors. The NHS and wider health and care sector has faced unprecedented workforce shortages and pressures in recent years. Yet, the most recent NHS staff survey illustrates that approximately half of staff do not feel recognised at work. NHS England has drawn on research and evidence and has worked with NHS organisations to develop this framework. It provides simple, easy-to-follow guidance and ideas for organisations to inform their own strategies and approaches.
  23. Content Article
    The only masking that’s going on is that of the government’s continued failure to get to grips with the virus, writes George Monbiot in this Guardian opinion piece. For some people, going to hospital may now be more dangerous than staying at home untreated. Many clinically vulnerable people fear, sometimes with good reason, that a visit to hospital or the doctors’ surgery could be the end of them. Of course, there have always been dangers where sick people gather. But, until now, health services have sought to minimise them. Astonishingly, this is often no longer the case. Across the UK, over the past two years, the NHS has been standing down even the most basic precautions against Covid-19. For example, staff in many surgeries and hospitals are no longer required to wear face masks in most clinical settings. Reassuring posters have appeared even in cancer wards, where patients might be severely immunocompromised. A notice, photographed and posted on social media last week, tells people that while they are “no longer required to wear a mask in this area”, they should use hand sanitiser “to protect our vulnerable patients, visitors and our staff”. Sanitising is good practice. But Covid-19 is an airborne virus, which spreads further and faster by exhalation than by touch.
  24. News Article
    NHS England has recorded more than 120,000 breaches of its mixed-sex hospital accommodation guidance in the past six years, a 257% increase. Guidance added to the NHS constitution in 2012 states that hospital patients will not share sleeping accommodation with members of the opposite sex “except where appropriate”. Exemptions include critical care wards or patients receiving treatment, such as chemotherapy, where they “may derive comfort from the presence of other patients with similar conditions”. The guidance also says patients should not share toilet or bathroom facilities with members of the opposite sex and should not “have to walk through an area occupied by patients of the opposite sex to reach toilets or bathrooms”. However, data from NHS England analysed by the Observer shows thousands of breaches every month, with patient dignity and safety put at risk. Caitlin (not her real name) worked on an acute mental health ward in a private hospital which switched from 12 women-only beds to 15 mixed beds. “Women on our ward often had a history of sexual or domestic abuse,” she said. “Some had tried to end their life in the wake of this, and a lot of them felt intimidated by the level of aggression shown by some men on the ward.” Women and men had separate wings but shared a communal area. “A lot of the women were really fearful of the men,” she added. Caitlin said the use of mixed-sex accommodation had a negative impact on some women’s recovery. “Women would stay in their rooms, not even coming out to watch TV,” she says. “Some acutely unwell women would display sexually disinhibited behaviour in the communal areas, which is a symptom of their diagnosis. They were put in a position where their dignity could not be protected.” “Women make hundreds of conscious and unconscious decisions to keep ourselves safe from men,” said Karen Ingala-Smith, author of Defending Women’s Spaces. “Women should not have to be on their guard like this when they are in hospital.” Read full story Source: The Guardian, 15 October 2023
  25. News Article
    Imagine being on your period and "forced to beg for pads and tampons". According to 24-year-old Lara, that's common for her and others on mental health hospital wards in the UK. When she posted about her experience online, people from across the country responded with their own similar stories. Mental health hospitals have various rules in place for safety reasons, including access to certain items. However, NHS guidance states that period products should be available to anyone who needs them. Lara says this hasn't always been the case for her. "I've had a number of hospital admissions to psychiatric units and on one of my first they confiscated my period products," she says. Lara's currently on one-to-one observations for her own safety, which means someone has to escort her to the toilet and watch her change a pad or tampon. But she says her worst experience was when she's had to wear anti-ligature clothing - again for safety reasons. "I was forced to remove my pants and sanitary pad - which meant I just had to bleed into the clothing," she says. "I understand the need for safety to come first, but this experience was unhygienic, traumatising and embarrassing for people to see." Eleanor is 20 years old and recently spent time in a mental health hospital. At her "most unwell", she says she didn't have access to her own clothing and had to wear the same special clothing Lara spoke about. "I'd have two or three people watching me changing and even though I know it's for my own safety, it's dehumanising," she says. Newsbeat asked a number of unions, organisations and charities to comment on the experiences described but none wanted to provide one. But one mental health professional, Kasper, did agree to discuss it. Kasper agrees that safety is always a top priority but adequate period provision is often overlooked."I'm sure all trusts have a policy, but don't think it's always applied - and my observation is that it very much depends on what staff are on shift, especially when there can be lots of agency workers," Kasper says."We do keep products on my ward, but there's not much of a range. "Patients can't access them and some staff don't know where they are either - so the onus is very much on patients, which can be tricky when they're unwell." Read full story Source: BBC News, 16 October 2023
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