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Patient Safety Learning

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  1. News Article
    The NHS has to train two GPs to produce one full-time family doctor because so many have started to work part-time, new research reveals. The finding helps explain why GP surgeries are still struggling to give patients appointments as quickly as they would like, despite growing numbers of doctors training to become a GP. The disclosure is contained in a report by the Nuffield Trust health thinktank that lays bare the large number of nurses, midwives and doctors who quit during their training or early in their careers. “These high dropout rates are in nobody’s interest,” said Dr Billy Palmer, a senior fellow at the thinktank and co-author of the report. “They’re wasteful for the taxpayer, often distressing for the students and staff who leave, stressful for the staff left behind, and ultimately erode the NHS’s ability to deliver safe and high-quality care.” Read full story Source: The Guardian, 28 September 2023
  2. News Article
    Parents are being urged to get their children vaccinated against measles, mumps and rubella (MMR) after a “worrying” drop in uptake of key vaccines. Figures from NHS England and the UK Health Security Agency (UKHSA) show 92.5% of children had had the first dose of the MMR jab at five years old by 2022-23, the lowest since 2010-11. The proportion of five-year-olds who had had the second jab by 2022-23 was 84.5%, also the lowest level since 2010-11. Vaccination programmes across England failed to meet the uptake recommended by the World Health Organization (WHO) for the year 2022-23. WHO recommends that, nationally, at least 95% of children should be inoculated for diseases that can be stopped by vaccines, in order to prevent outbreaks. NHS data showed no routine vaccine programme met the threshold during the 12-month period. Dr Gayatri Amirthalingam, a consultant medical epidemiologist at UKHSA, said the downward trend was a “serious concern”. “The diseases that these vaccines protect against, such as measles, polio and meningitis, can be life-changing and even deadly,” she said. “No parent wants this for their child especially when these diseases are easily preventable. Please don’t put this off, check now that your children are fully up to date with all their vaccines due. Check your child’s red book and get in touch with your GP surgery if you are not sure.” Read full story Source: The Guardian, 29 September 2023
  3. News Article
    Women have faced delays in giving birth due to the ongoing strikes, a major trust’s chief executive has said. Matthew Hopkins, who joined Mid and South Essex Foundation Trust last month, told a board meeting on Thursday that industrial action was having a “significant and growing” impact on patients. He added that this extended beyond delays to outpatient appointments and elective operations, saying: “It is also delaying mums giving birth, because we are seeing delays now in being able to conduct our elective Caesarian sections.” Mr Hopkins said the impact was also “really significant” on staff, with those covering for colleagues “very, very tired”. “It is important we give a very clear message to the two sides of the argument – government and the [British Medical Association] – that we need a light at the end of the tunnel, and staff need a light at the end of the tunnel. “Going into winter, with this continuing disruption for our patients and our staff, is in my view unacceptable.” Read full story (paywalled) Source: HSJ, 28 September 2023
  4. Content Article
    CHIRP was formed in 1982 as a result of a joint initiative between the Chief Scientific Officer Civil Aviation Authority (CAA), the Chief Medical Officer CAA and the Commandant Royal Air Force Institute of Aviation Medicine (IAM).   The programme was based on the Aviation Safety Reporting System (ASRS) that had been formed in the United States of America in 1976 under the management of National Aeronautical and Space Administration (NASA). 
  5. Content Article
    Evidence shows that when patients are treated as partners in their care, then safety, patient satisfaction and health outcomes improve. To mark World Patient Safety Day 2023, this podcast episode discusses the importance of engaging with patients and how it contributes towards increased patient safety in health and social care settings. Healthcare Improvement speak to a number of professionals from Healthcare Improvement Scotland, as well as Lisa McDowall, a Senior Charge Nurse at Jubilee Hospital in Grampian. We also spoke with Gareth Bourhill who lost his mum in the Vale of Leven c-difficile outbreak of 2007 to 2008, and is now a public partner with our organisation’s Excellence in Care team.
  6. Content Article
    In anticipation of an increase in patients requiring a temporary tracheostomy due to the huge surge in patients placed on ICU ventilation at the peak of the COVID-19 pandemic, the NHS England National Patient Safety Team launched a National Patient Safety Improvement programme to rapidly support the NHS to provide safe tracheostomy care.
  7. Content Article
    CQC's completed programme, which started in 2014, of comprehensive inspections of all specialist mental health services in England.
  8. Event
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    Climate change has been recognised as the “biggest global health threat of the 21st Century”. Healthcare is one of the most significant contributors to greenhouse gas emissions and there are steps which healthcare professionals and organisations can and should be taking to tackle this issue. In 2020, the NHS set out a bold ambition to become the world’s first carbon net zero national health system by 2045. The Safety For All campaign is hosting a webinar on the topic of sustainability where attendees will have the opportunity to hear from the Chair of the ABHI’s Sustainability Group and Chair of the Sustainable Healthcare Coalition. The webinar is free to attend and open to everyone with an interest in the importance of sustainability in healthcare. Speakers: Michelle Sullivan and Fiona Adshead. Register
  9. Content Article
    Harold Pedley, known as Derek, attended his GP surgery during the late afternoon on 21.12.22 and after spending most of that day feeling unwell with symptoms including abdominal pain and vomiting. He was appropriately referred to the hospital and travelled there with his friend after his GP had discussed his case with doctors. Due to a lack of available beds in the assessment unit, Derek needed to remain in the emergency department. Following his arrival at 20.07 hours, doctors were not notified of his attendance. He remained in the emergency department waiting area for almost two hours during which time due to significant pressures faced by the department he was not assessed or spoken to by a medical professional. At 21.59 hours a triage nurse called for him. By then, Derek had been unresponsive for some time and had died, his death confirmed at 22.26 hours. A subsequent post mortem examination revealed he died from the effects of non-survivable extensive small bowel ischaemia caused by a significantly narrowed mesenteric artery. His death was contributed to by heart disease.
  10. News Article
    Millions of people wrongly believe they are allergic to penicillin, which could mean they take longer to recover after an infection, pharmacists say. About four million people in the UK have the drug allergy on their medical record - but when tested, 90% of them are not allergic, research suggests. The Royal Pharmaceutical Society says many people confuse antibiotic side-effects with an allergic reaction. Common allergic symptoms include itchy skin, a raised rash and swelling. Nausea, breathlessness, coughing, diarrhoea and a runny nose are some of the others. But antibiotics, which treat bacterial infections, can themselves cause nausea or diarrhoea and the underlying infection can also lead to a rash. And this means people often mistakenly believe they are allergic to penicillin, which is in many good, common antibiotics. These are used to treat chest, skin and urinary tract infections - but if people are labelled allergic, they are given second-choice antibiotics, which can be less effective. Read full story Source: BBC News, 28 September 2023
  11. News Article
    More than half of staff at a hospital trust that has been under fire for its "toxic culture" have said they felt bullied or harassed. The findings come from an independent review commissioned by University Hospitals Birmingham (UHB) NHS Trust. It has been at the centre of NHS scrutiny after a culture of fear was uncovered in a BBC Newsnight investigation. UHB has apologised for "unacceptable behaviours". It added it was committed to changing the working environment. Of 2,884 respondents to a staff survey, 53% said they had felt bullied or harassed at work, while only 16% believed their concerns would be taken up by their employer. Many said they were fearful to complain "as they believed it could worsen the situation," the review team found. Read full story Source: BBC News, 27 September 2023
  12. Content Article
    The Culture Review report was published following an independent external review of the organisational culture at University Hospitals Birmingham Trust. The external review was carried out by consultancy firm The Value Circle following a series of investigations into problems at University Hospitals Birmingham Foundation Trust over the last year.
  13. Event
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    This Westminster Health Forum conference focuses on key priorities and next steps for dentistry in England. Delegates will discuss next steps for service recovery following pandemic disruption, with funding from the Government last year aimed at managing backlogs. Policy-makers and dentistry stakeholders will assess findings from the Health and Social Care Select Committee inquiry published in the summer, which looked at accessibility to NHS dentistry, the Dental Contract and the workforce. Sessions in the agenda will look at next steps, including issues around workforce retention and the future sustainability of the profession. The Westminster Health Forum conference will also be an opportunity to discuss the 2022-2023 contract reform agreements, focusing on impact so far and the way forward as integrated care systems implement their responsibilities for commissioning dentistry services - as well as the role of dentistry within development of ICSs, and prospects for further development and support for dentistry. Delegates will look at priorities for delivering efficient oral healthcare and the wider drive to improve prevention, including the impact of pooled budgets, and priorities for building dental teams. Overall, areas for discussion include: service restoration: addressing backlogs in balance with safety and infection control - balancing routine appointment catch-up with delivering emergency dental care - the impact of funding. dental contract reform: possible outcomes and implications for the sector - providing clarity following prototype practices being dropped - impact of the pandemic. workforce: assessing reform to dentistry education and training - progress since the Advancing Dental Care Review - concerns around retention and the future sustainability of the profession. integrated care: the role of dentistry within ICSs, as well as the wider focus on prevention - changes to commissioning - the impact of pooled budgets on dentistry. accessibility: identifying and overcoming barriers to access - improving the availability of services - addressing health inequalities. integrated oral care: the role of dentistry in preventative healthcare - the impact of commissioning changes. professional regulation: the priorities and outlook for reform for the dentistry profession - options for streamlining and efficiency - standards and support for the sector. Register
  14. News Article
    Health experts are calling for a “feminist approach” to cancer to eliminate inequalities, as research reveals 800,000 women worldwide are dying needlessly every year because they are denied optimal care. Cancer is one of the biggest killers of women and ranks in their top three causes of premature deaths in almost every country on every continent. But gender inequality and discrimination are reducing women’s opportunities to avoid cancer risks and impeding their ability to get a timely diagnosis and quality care, according to a new Lancet Commission on women, power and cancer. The largest report of its kind, which studied women and cancer in 185 countries, found unequal power dynamics across society globally were having “resounding negative impacts” on how women experience cancer prevention and treatment. Gender inequalities are also hindering women’s professional advancement as leaders in cancer research, practice and policymaking, which in turn perpetuates the lack of women-centred cancer prevention and care, the report adds. It is calling for a new feminist agenda for cancer care to eliminate gender inequality. Read full story Source: The Guardian, 26 September 2023
  15. Content Article
    Women interact with cancer in complex ways, as healthy individuals participating in cancer prevention, as patients, as health professionals, researchers, policymakers, and as unpaid caregivers. In all these domains, women often are subject to overlapping forms of discrimination, such as due to age, race, ethnicity and socio-economic status, that render them structurally marginalised. These myriad factors can restrict a woman’s rights and opportunities to avoid cancer risks, are a barrier to diagnosis and quality cancer care, maintain an unpaid caregiver workforce that is predominantly female, and hinder women’s professional advancement.
  16. News Article
    MSPs are set to vote on a new law to establish a patient safety commissioner. The bill to create an "independent public advocate" for patients will go through its final stage on Wednesday. Public Health Minister Jenny Minto has said the commissioner would be able to challenge the healthcare system and ensure patient voices were heard. The Scottish government has been told the new watchdog must have the power to prevent future scandals. In 2020, former UK Health Minister Baroness Julia Cumberlege published a review into the safety of medicines and medical devices like Primodos, transvaginal mesh and the epilepsy drug sodium valproate. She told the House of Lords: "Warnings ignored. Patients' concerns ignored. A system that seemed unwilling or unable to listen let alone respond, unwilling or unable to stop the harm." Her findings led to the recommendation for a patient safety commissioner. Speaking ahead of the vote on the Patient Safety Commissioner for Scotland Bill, Ms Minto said the watchdog would listen to patients' views. "I think it's a really important role for us to have in Scotland," she said. "There's been a number of inquiries or situations where the patient's voice really needs to be listened to and that's what a patient safety commissioner will do." Read full story Source: BBC News, 27 September 2023
  17. Content Article
    Mental health in the UK is getting worse. Sickness absence due to mental illness is soaring, rates of mental health difficulties are increasing at an alarming rate, and already overstretched services are struggling to meet rising demands. Along with over 30 organisations with an interest in mental health, the Centre for Mental Health has developed a plan to address this and build a mentally healthier nation.
  18. News Article
    A consultant obstetrician has claimed he was sacked from his hospital for raising whistleblowing concerns about patient safety over fears they would cause “reputational damage”. Martyn Pitman told an employment tribunal in Southampton that managers dismissed his concerns and he was “subjected to brutal retaliatory victimisation” after he criticised senior midwife colleagues. He said: “On a daily basis there was evidence of deteriorating standards of care. We were certain that the situation posed a direct threat to both patients’ safety and staff wellbeing. Concern was expressed that there was a genuine risk that we could start to see avoidable patient disasters.” Rather than addressing these, Pitman said the trust had considered it “the path of least resistance to take out [the] whistleblower”. Pitman was dismissed this year from his job at the Royal Hampshire County hospital (RHCH) in Winchester, where he had worked as a consultant for 20 years. He is claiming he suffered a detriment due to exercising rights under the Public Interest Disclosure Act. He said he “fought against [an] absolute barrage of completely unprofessional assaults on me” after he raised concerns about foetal monitoring problems that resulted in the death of a baby and the delivery of another with severe cerebral palsy. Read full story Source: The Guardian, 26 September 2023
  19. News Article
    The message that vaping is 95% safer than smoking has backfired, encouraging some children to vape, says a top health expert. Dr Mike McKean treats children with lung conditions and is vice-president for policy at the Royal College of Paediatrics and Child Health. He says the 2015 public messaging should have been clearer - vapes are only for adults addicted to cigarettes. Evidence on the possible health risks of vaping is still being gathered. In an exclusive interview with the BBC, Dr McKean said: "Vaping is not for children and young people. In fact it could be very bad for you," although he stresses that it is not making lots of children very sick, and serious complications are rare. "Vaping is only a tool for adults who are addicted to cigarettes." He says the 95% safe messaging was "a very unwise thing to have done and it's opened the door to significant chaos". "There are many children, young people who have taken up vaping who never intended to smoke and are now likely addicted to vaping. And I think it's absolutely shocking that we've allowed that to happen." Read full story Source: BBC News, 26 September 2023
  20. Content Article
    The theme of this year’s World Patient Safety Day is ‘engaging patients for patient safety’. In this blog, Hester Wain, Head of Patient Safety Policy, along with Penny Phillips and Douglas Findlay, two of the patient safety partners working to support the national Patient Safety team, introduce NHS England’s work with patient safety partners. To support other organisations going through this process, the blog also shares some of the approaches NHS England has taken in introducing patient safety partners.
  21. Content Article
    Standardising community pharmacy information so it can be shared digitally should reduce the burden on GPs and lead to safer, more personalised care, writes Stephen Goundrey-Smith. The Professional Record Standards Body’s (PRSB) Community Pharmacy Standard enables information to be recorded in the community pharmacy and sent to the person’s GP and all the services covered by the England Community Pharmacy Contractual Framework. Having access to better information will allow the community pharmacy team to take on a greater range of clinical services and reduce the burden on GPs and other parts of the health and care system. It will also raise the profile of the clinical contribution that community pharmacists make to the wider NHS.
  22. News Article
    Police forces in parts of the UK have stopped answering urgent calls related to mental health even before alternative support is available to people, under a policy designed to free up officers’ time, MPs were told last week. The move means many vulnerable people are being left without help in areas where the necessary services and arrangements with other agencies are not yet in place, warned Sarah Hughes, chief executive of the mental health charity Mind. Giving evidence to the House of Commons health select committee on Tuesday 19 September, Hughes said, “We know of local Mind and local trust partners who are already experiencing people having no response because the police are saying they no longer respond to mental health calls.” The policy, Right Care, Right Person, which was developed by Humberside Police over nearly three years, is being rolled out in England and Wales from the end of October at varying speeds. Backed by the government and police representative bodies, it aims to ensure that patients in a mental health crisis are treated by the most appropriate agency, rather than have police act as default responder, when they may not be best suited to help. But the Royal College of Psychiatrists is among the organisations to have raised concerns over the levels of preparation and resourcing for the policy and the absence of evaluation of clinical outcomes or benefits and harms to the population. Read full story (paywalled) Source: BMJ, 25 September 2023
  23. News Article
    Thousands of people with asthma and other lung problems are going undiagnosed because most GPs in England do not offer tests for them, according to a new report. The failure to diagnose and start treating people with breathing problems threatens to create “a deluge of hospital admissions this winter” when the NHS is under intense pressure. Sarah Woolnough, the chief executive of charity Asthma and Lung UK, said: “The abysmal lack of testing and patchy basic care is causing avoidable harm to people with lung conditions and the NHS.” The report, which the Charity Commissioned from consultants PricewaterhouseCoopers, found that most GP surgeries in England do not provide basic lung function tests. Patients’ inability to access a test to check if they have asthma or chronic obstructive pulmonary disease (COPD) represents a “crisis in care” that could lead to many being hospitalised this winter “as respiratory viruses take hold and people struggle to heat their homes”, Asthma and Lung UK added. Read full story Source: The Guardian, 26 September 2023
  24. Content Article
    In this article, Sharon Hartles highlights the high-profile legal battle involving numerous Primodos-affected claimants against pharmaceutical companies and the government. The court ruled against the claimants, dismissing their claims related to hormone pregnancy tests and foetal harm. This decision led to disappointment and criticism from advocates, MPs, and academics involved in the Primodos scandal. Sharon Hartles is affiliated with the Risky Hormones research project, which is an international collaboration in partnership with patient groups. Additionally, she is a member of the Harm and Evidence Research Collaborative at the Open University. Related reading on the hub: Primodos 2023: The fight for justice continues for the Association for Children Damaged by Hormone Pregnancy Tests Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response Primodos: The next steps towards justice Patient Safety Spotlight interview with Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests
  25. Event
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    This webinar is open to DoF's/CFOs and deputies only. On average 11,000 deaths a year are classed as avoidable with that number probably tripling in the years following the pandemic. Patient Safety Learning is a charity and independent voice for improving patient safety. They harness the knowledge, enthusiasm and commitment of healthcare organisations, professionals and patients for system-wide change and the reduction of preventable harm. They provide a wealth of free resources on the hub and they are on a mission to align leadership and frontline delivery of care; ensuring that patient safety is a core purpose in the development of integrated care. ICSs present a significant opportunity to drive improvements in patient safety in local health systems across the NHS. However, patient safety remains the ‘elephant in the room’ in the development of ICS roles and responsibilities. Helen will bring a unique perspective to this session as an ex-NHS finance director, she understands the pressure and conflicting priorities faced by NHS leaders. But with between 13 – 15% of yearly spending being attributed to patient safety issues. Not only morally is this an issue that needs to be addressed but getting it right can also have a big impact on the bottom line. This is the second webinar running as part of the HFMA Connect network. Join this supportive community dedicated to assisting NHS finance leaders like you, being run in collaboration with the HFMA Hub partnership. This new network facilitates knowledge sharing and looks to assist directors of finance, chief finance officers and deputies as they navigate the current challenges facing the NHS. Register
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