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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Patients need to be involved in all aspects of the design and delivery of healthcare and to make quality improvements that prevent harm. The Patient Safety Commissioner website shows examples of where working in partnership with patients and families, listening to patients’ voice and acting upon their concerns have made positive changes.  
  2. Content Article
    Watch this World Patient Safety Day webinar with Nigel Roberts on enhancing patient safety and surgical outcomes with the surgical safety checklist.
  3. Content Article Comment
    @Vanessa Williams We haven’t created a Teams / Zoom backdrop for the image but I would imagine most competent NHS IT departments could do this for their staff. Tracy and I are happy for teams to use the image in this manner if they so wish. Stephen
  4. Content Article
    David Lawson, who leads the Department of Health and Social Care medtech directorate, outlines how the medtech strategy will be implemented with patients.
  5. Content Article
    Dr Kristin Harris, Research Fellow in the Department of Anaesthesia and Critical Care at Haukeland University Hospital, Bergen, Norway, discusses why patient safety patient involvement personally matters to her and talks about the tool she's currently working on, which are safety checklists specific to surgical patients.
  6. Content Article
    In honour of World Health Organization World Patient Safety Day 2023, the Patient Safety Movement Foundation hosted a webinar dedicated to the theme of “Empowering Patients.”
  7. Content Article
    The NHS-Virginia Mason Improvement Partnership was a five-year programme where five NHS organisations implemented organisation-wide improvement. The evaluation, led by Dr Nicola Burgess of University of Warwick - Warwick Business School offers profound lessons on how to create a culture and system for continuous improvement. The six lessons from the evaluation are now available in a free eBook.
  8. Content Article
    Patients’ perspectives and their active engagement are critical to make health systems safer and people-centred, and are key for co-designing health services and co-producing good health with healthcare professionals, and building trust in health systems. This report, which forms part of a series of Organisation for Economic Co-operation and Development (OECD) papers on the economics of patient safety, looks (i) the economic impact of patient engagement for patient safety; (ii) the results of a pilot data collection to measure patient-reported experiences of safety and; (iii) the status of initiatives on patient engagement for patient safety taken in 21 countries, which responded to a snapshot survey.
  9. Content Article
    In a world where most people wake up with the sun and head to their ‘9 to 5’, night shift work can be a challenge – but can it also be bad for your health? What do those health effects mean for your risk of cancer? Can working night shifts cause cancer? Worldwide Cancer Research presents the evidence.
  10. Content Article
    The Institute of Global Health Innovation (IGHI), Imperial College Healthcare NHS Trust and NIHR North West London Patient Safety Research Collaboration hosted a virtual event to celebrate World Patient Safety Day, chaired by Professor Bryony Dean-Franklin. The event started with keynote speeches from Professor the Lord Ara Darzi, Co-Director of IGHI; Dr Henrietta Hughes, England’s Patient Safety Commissioner; and Rosie Bartel, patient advocate, emphasising the importance of hearing patient’s voices. This was followed by an excellent panel session on how clinicians, researchers, and patients and carers can work together to support patients and their families to feel safe and engage with their care. The event was co-designed with patient representatives from NIHR North West London Patient Safety Research Collaboration and Imperial College Healthcare NHS Trust.
  11. News Article
    Patients with Parkinson’s disease are being put at risk when they have spells in hospital due to a lack of timely medication, according to a new report. Some 58% of people with Parkinson’s disease who were admitted to hospital in England last year said that they did not receive their medication on time during their stay. Parkinson’s UK said that medication for people with the condition is “time critical” and a delay of 30 minutes can mean the difference between functioning well and being unable to move, walk, talk or swallow. The charity also conducted freedom of information requests on English hospitals and found that one in four (26%) NHS trusts do not have policies that allow people with Parkinson’s to take their own medication in hospitals. Only half (52%) require staff responsible for prescribing and administering medication to have training on time critical medication, the charity found. Parkinson’s UK has called for a number of measures to be put in place to make sure patients in hospital can get access to medications when needed including: ensuring there are medication self-administration policies for patients where it is safe to do so; more training for staff and better use of e-prescribing to keep on track of medication timings. Read full story Source: The Independent, 19 September 2023
  12. Content Article
    People with Parkinson’s need their medication on time every time. Yet over half of people with the condition don’t get their medications on time in hospital. This can cause stress, anxiety, immobility, severe tremors, and in some extreme cases death. Parkinson's UK are campaigning to make sure that no one with Parkinson’s is worried that they will leave hospital more unwell than when they went in.  Whether you have Parkinson’s, support someone who does, work in the health and care system or campaign to improve it, you can take action to make hospitals and care homes safer.  Together we can get more people to understand how big this problem is. And we can put pressure on the right people, across the UK, to change hospital policies, improve prescribing in hospitals and make sure staff are trained to give time critical medication.
  13. News Article
    The NHS has declared 22 ‘critical incidents’ due to disruption caused by industrial action since December, including having to transfer critical care patients, according to the Department for Health and Social Care. Critical care and gynaecology patients have had to be moved to other hospitals due to staffing shortages, urgent cancer surgery and chemotherapy appointments have had to be rescheduled and urgent surgery on trauma patients “could not go ahead” during critical incidents declared in periods of strike action since December, the Department of Health and Social Care said. There have been strikes by both doctors and Agenda for Change staff over pay during 2023, and Wednesday sees junior doctors and medical consultants strike on the same day for the first time. The DHSC has not previously revealed critical incidents caused by strikes, nor details of them. Trusts typically have different triggers for declaring critical incidents, but they indicate severe strain on services, and it is not unusual for them to happen during high winter pressures. Read full story (paywalled) Source: HSJ, 20 September 2023
  14. News Article
    Paramedics and A&E doctors often miss signs of sepsis and two of the four ways health professionals screen for the killer condition do not work, a new study claims. Doctors, NHS bosses and health charities have been concerned for years that too many cases of sepsis go undiagnosed, leaving people badly damaged or dead, because sepsis is so hard to detect. Unless a patient is diagnosed quickly, their body’s immune system goes into overdrive in response to an infection and then attacks vital tissues and organs. If left untreated, sepsis can cause shock, organ failure and death. Research from Germany, presented at this week’s European Emergency Medicine Congress in Barcelona, claims to have uncovered significant flaws in two of the four screening tools that health workers use worldwide to identify cases of the life-threatening illness. The four systems are NEWS2 (National Early Warning Score), qSOFA (quick Sequential Organ Failure Assessment), MEWS (Modified Early Warning Score) and SIRS (Systemic Inflammatory Response Syndrome). The researchers analysed records of the care given to 221,429 patients in Germany who were treated by emergency health workers outside hospital settings in 2016. “Only one of four screening tools had a reasonably accurate prediction rate for sepsis – NEWS2. It was able to correctly predict 72.2% of all sepsis cases and correctly identified 81.4% of negative, non-septic cases,” they concluded. NHS England stressed that it already deploys NEWS2, which emerged as the best system. An NHS spokesperson said: “This study shows the NHS actually is using the best screening tool available for detecting sepsis – NEWS2 – and as professional guidance for doctors in England sets out, it is essential that any patient’s wishes to seek a second opinion are respected.” Read full story Source: Guardian, 20 September 2023
  15. Content Article
    The 'Learning Response Review and Improvement Tool' is intended to be used by: Those writing learning response reports following a patient safety incident or complaint, to inform the development of the written report. Peer reviewers of written reports to provide constructive feedback on the quality of reports and to learn from the approach of others. Development of this tool and set of standards was informed by a research study from Paul Bowie, Programme Director for Safety & Improvement at NHS Education for Scotland (NES), identified ‘traps to avoid’ in safety investigations and report writing. The tool was originally developed by NHS Scotland. It has been further refined in collaboration with HSIB and NHS England after being piloted in approximately 20 NHS trusts and healthcare organisations in England. The content validity of the tool is currently being assessed.
  16. Content Article
    The latest data from the Office for National Statistics (ONS) provides the most comprehensive and up to date national profile of ethnic inequalities in mortality overall and from common physical conditions. It shows a complex picture of ethnic inequalities in mortality in England, with differences between people from ethnic minority and the White British groups, between different ethnic minority groups, and across different health conditions. This King's Fund blog looks at the complex interplay of factors drives ethnic differences in health.
  17. News Article
    The Nigerian government has developed the National Policy and Implementation Strategy on Patient Safety and Healthcare Quality. The development, the government said, is part of efforts to improve the safety of all medical procedures and enhance the quality of healthcare delivery. The Permanent Secretary at the Federal Ministry of Health, Kachollom Daju, disclosed this at a press briefing in Abuja on Monday. At the briefing, which was in commemoration of the 2023 World Patient Safety Day, Ms Daju said the national policy is in line with resolution 18 of the 55th World Health Assembly which called for member states to recognise the burden of patient safety and to set up policies to manage them. “This policy focuses on improving patient and family engagement in healthcare, medication safety, surgical safety, infection prevention & control, safety of all medical procedures and others,” said Ms Daju. She said the federal government is hopeful that health facilities at all levels will adopt and implement this policy. She noted that patient safety fundamentally entails preventing errors and minimising harm to patients during provision of healthcare services. Read full story Source: Premium Times, 19 September 2023
  18. Content Article
    The Forgiveness Project shares stories of forgiveness in order to build hope, empathy and understanding.
  19. News Article
    More patients than ever before will be put at risk when consultants and junior doctors begin the “biggest walkout the NHS has ever seen”, the body that speaks for health trusts has warned. The latest round of industrial action in England, when consultants will strike in a dispute over pay on Tuesday and Wednesday and junior doctors on Wednesday, Thursday and Friday, would force hospitals to cancel a higher number of appointments and operations than ever before, the NHS Confederation revealed. Among the patients who were being placed in the greatest danger were the increasing number of people who have already had their operations cancelled due to strike action, and now face having their rescheduled appointments cancelled again, health officials have warned. That included growing numbers of cancer patients, who were expected to be more affected than in previous rounds of strikes. The government will launch a consultation on Tuesday over plans to impose new regulations on striking doctors and nurses to ensure hospitals provide a minimum level of cover. The regulations, which would cover urgent, emergency and “time-critical” hospital-based health services, would mean that employers could issue a “work notice” compelling doctors and nurses to work during industrial action, in order to maintain “necessary and safe levels of service”. Clinicians who still take industrial action could run the risk of losing their job. Read full story Source: The Guardian, 19 September 2023
  20. News Article
    A man claims he lost his sight in one eye after routine cataract surgery left him in "unbelievable" pain. John Stabler, from East Yorkshire, is set to sue the maker of an artificial lens he had fitted last year and which was later recalled over safety fears. The 63-year-old said he felt like he had been hit "with a sledgehammer" after the operation and had suffered "catastrophic" loss of income. Manufacturer Nidek said it "profoundly regrets" any patient suffering. Mr Stabler is one of 14 patients seeking compensation over the company's EyeCee One Preloaded lens. He said he had suffered permanent nerve damage to his left eye after having the lens fitted at Hull and East Yorkshire Eye Hospital in October last year. He told the BBC: "About two days after, I was getting really bad pain. It was unbelievable. It was like someone was hitting me with a sledgehammer." NHS England issued a safety alert in January 2023 after Nidek announced a "voluntary and precautionary" global product recall of its EyeCee One and EyeCee One Crystal intraocular lenses. UK distributor Bausch + Lomb said there has been "a limited number of reports of elevated intraocular pressure in patients". Read full story Source: BBC News, 19 September 2023
  21. News Article
    A national NHS leader has said regulation of managers ‘is coming’, and the service should ‘just go with it and make it as effective’ as possible. Sir Jim Mackey, national director for elective recovery and the chief executive of Northumbria Healthcare Foundation Trust, also told HSJ that regulation could offer better “protection” for management staff if implemented properly. NHS England is considering additional regulation of NHS management after being asked to “revisit” the idea by health and social care secretary Steve Barclay in the wake of the murder of babies by nurse Lucy Letby at the Countess of Chester Hospital. In an interview with HSJ, Sir Jim said: “Honestly, I think it’s coming. So we just need to go with it and make it as effective as it can be. It’s completely understandable in the current context for politicians and the public to want people in these positions to be regulated.” He continued: “There’s potentially some protection for people in being regulated in an effective way, as well as [being subject to] clear rules, clear processes. If somebody makes an allegation and it’s found to be wrong [and] you’ve been through a thorough regulatory process, it’s going to help you to move on and put it behind you.” Read full story (paywalled) Source: HSJ, 18 September 2023
  22. Content Article
    The World Health Organization (WHO) launched the Global Knowledge Sharing Platform for Patient Safety (GKPS) at the World Patient Safety Day 2023 Global Conference on 13 September 2023. GKPS is an online and public platform to facilitate systematic collection and sharing of patient safety knowledge by stakeholders in different geographic regions, economics and cultural settings. It promotes the sharing of best practices related to the theme of each World Patient Safety Day for implementing and learning, as well as sharing of experience in enhancing patient safety.  
  23. Content Article
    The focus of this year's World Patient Safety Day is engaging patients in “recognition of the crucial role patients, families and caregivers play in the safety of healthcare”. In this Comment in the Lancet, Jane O'Hara and Carolyn Canfield outline how supporting patients and families to be partners in care safety is both a logical and moral imperative. That is, we need to do it for safer care, but we also should do it because safer care relies on relationships, reciprocal trust, and collaboration.
  24. News Article
    NHS England has warned the decision by police forces to respond to far fewer incidents involving people in mental distress could pose ‘risks’ to both patients and a service “already under enormous pressure”. National mental health director Claire Murdoch has written to integrated care board leaders and mental health trust CEOs about the possible impact of the “right care, right person” policing model which is being rolled out across England. In July, policing minister Chris Philp gave all forces the green light to implement the RCRP model. The approach was first trialled in Humberside and involves officers only attending mental health calls where there is a risk to life or serious harm. Now, in a letter seen by HSJ, Ms Murdoch has admitted the new model is a “major change for services already under enormous pressure” and warns that implementing all of the actions set out in the national partnership agreement may take time between the police and the NHS. This took three years in Humberside, she notes. Ms Murdoch wrote: “I know you will all be doing your best to make this work, but I am so mindful of the risks to services and people with mental health problems, as I am sure you are too.” Read full story (paywalled) Source: HSJ, 15 September 2023
  25. News Article
    The deputy leader of a trust rated ‘inadequate’ by a health watchdog four times in the past decade has admitted the necessary changes to its culture may take a further four years. Norfolk and Suffolk Foundation Trust staved off calls to break it up earlier this year after the Care Quality Commission raised its rating from “inadequate” to “requires improvement”. However, it has come under increased scrutiny in recent months after a review found it lost track of patient deaths, and a subsequent BBC Newsnight investigation discovered the report was edited to remove criticism of its leadership. The BBC found earlier drafts removed references to a “culture of fear” highlighted by some staff. Now deputy CEO Cath Byford has addressed growing concerns about the morale of staff working at the organisation, and their ability to speak up, at a meeting of Norfolk County Council’s health overview and scrutiny committee. During the meeting, she revealed the results of an anonymous survey which received 18,000 staff interactions. Most feedback was “not positive” admitted Ms Byford. She said many staff reported bullying and harassment, unfairness, inequality, and nepotism. This was particularly the case in recruitment, with staff feeling jobs were being lined up for certain individuals. Read full story (paywalled) Source: HSJ, 15 September 2023
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