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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The Association of Ambulance Chief Executives (AACE) has published a new report charting the major increase in the frequency and length of hospital handover delays over the past ten years, calling for an even greater focus on improvements that will reduce and eradicate delays, prevent more patients from coming to significant harm and stop the drain on vital ambulance resources.
  2. Content Article
    PLACE assessments will provide motivation for improvement by providing a clear message, directly from patients, about how the environment or services might be enhanced. The 2023 programme is planned for launch in early September 2023.
  3. Content Article
    For World Patient Safety Day 2023, the NHS National Patient Safety Team have produced a series of bitesize videos around the theme of 'engaging patients for patient safety'. In this video, Joan Russell, head of patient safety (policy and partnerships), and Hester Wain, head of patient safety policy, in NHS England, talk about the background and history of formally involving patients to support the NHS to improve patient safety, and how this became part of the NHS Patient Safety Strategy, followed by the Framework for Involving Patients in Patient Safety. They go on to provide an update on the work to introduce Patient Safety Partners across the NHS and future plans.
  4. News Article
    A new regional centre which promotes the reporting of suspected safety concerns associated with healthcare products has been launched in Northern Ireland. The Yellow Card centre for Northern Ireland will bring together a dedicated team to increase awareness, educate, and promote reporting of suspected adverse events to the Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card scheme. The Yellow Card scheme provides a mechanism for patients, care givers and healthcare staff to report suspected safety concerns associated with healthcare products. Speaking at the launch of the new service, Northern Ireland Chief Pharmaceutical Officer Professor Cathy Harrison said: “Collecting and monitoring information on possible adverse effects of medications and healthcare products is vital to ensuring patient safety. "It is fitting that the launch of the Yellow Card centre for Northern Ireland coincides with World Patient Safety Day on 17 September, with this year’s theme of "Engaging patients for patient safety". "The Yellow Card scheme puts the patient voice at its heart. By voluntarily reporting issues, patients, families and care givers can play a crucial role in their own care, and the safety of healthcare as a whole. I welcome the launch of the new regional centre and would encourage anyone who has suspected safety concerns to report them.” Read full story Source: Department of Health (Northern Ireland), 13 September 2023
  5. News Article
    Children have suffered severe harm at two further hospital trusts as a result of failures in paediatric audiology, HSJ has revealed. HSJ reported in July that three children at Croydon Health Service Trust may have come to “severe harm” – meaning they may have suffered permanent damage – following failures in the trust’s processes in audiology. Now East and North Hertfordshire Trust and North West Anglia Foundation Trust have also confirmed a small number of cases of severe or serious harm; while some trusts have yet to confirm findings from case reviews they have carried out. Major problems emerged earlier this year, initially in Scotland, of poor quality checks missing children with hearing problems who should have received support, and of a failure to inspect the services. NHS England ordered a review of data from the national newborn screening programme which, alongside other review work, identified six English trusts as having likely failures in their service: Croydon, East and North Herts, North West Anglia, Warrington and Halton Hospitals, North Lincolnshire and Goole, and Worcestershire Acute Hospitals. Read full story (paywalled) Source: HSJ, 14 September 2023
  6. News Article
    ChatGPT could be used to diagnose patients in a bid to reduce waiting times in emergency departments, researchers have suggested. It comes after a study found the language model, powered by artificial intelligence (AI), “performed well” in generating a list of diagnoses for patients and suggesting the most likely option. Researchers in the Netherlands entered the records of 30 patients who visited an emergency department in 2022, as well as anonymous doctors’ notes, into ChatGPT versions 3.5 and 4.0. The AI analysis was compared to two clinicians who made a diagnosis based on the same information, both with and without laboratory data. When lab data was included, doctors had the correct answer in their top five differential diagnoses in 87% of cases, compared with 97% for ChatGPT 3.5 and 87% for ChatGPT 4.0. There was a 60% overlap between the differential diagnoses by clinicians and ChatGPT. The team said that while ChatGPT was “able to suggest medical diagnoses much like a human doctor would”, more work is needed before it is applied in the real world. Read full story Source: The Independent, 13 September 2023
  7. Content Article
    A report has been published by Healthcare Inspectorate Wales (HIW) setting out the findings of a review of patient flow in Wales. Patient flow is the movement of patients through a healthcare system from the point of admission to the point of discharge. HIW specifically examined the journey of patients through the stroke pathway. This was to understand what is being done to mitigate any harm to those awaiting care, as well as to understand how the quality and safety of care is being maintained throughout the stroke pathway.
  8. Gallery Image
    Blood pressure pills mistaken for thyroid pills.jpg
    Shared on X, formerly Twitter, by Zucker Doctor @DoctorLFC "Last month, a lady in her late 60s with a history of Hypothyroidism had come to see me. Her thyroid reports were out if range (TSH was 25). She said she had been on an early morning 50 power (mcg) thyroid pill for the past 10 years. Same dose, doesn't miss her meds, takes it on on empty stomach and maintains a 45 minutes gap between her thyorid pill and her tea/breakfast. Her 2022 Thyroid reports were bang normal. Something was amiss. She hadn't carried her medicines along so I asked her to bring the bottle (she stayed close by). She came back with a bottle of a dual combination antihypertensive drug (see pic). She did not have a history of high BP and her BP reading in clinic was 100/60. She insisted this was her thyorid pill. When I explained that this is a drug for high blood pressure management, something struck her, she said she will return in 10 minutes and rushed back home. She returned with her thyroid pill bottle (see pic again). Her husband has a history of hypertension and for the past one year, due to some confusion, she was taking her husband's BP pill and her husband was taking her thyroid pill. Their son would routinely take the respective bottles to the chemist as and when the pills were about to get over and the chemist would give a new one without a fresh prescription. Probably a year ago, the two bottles got exchanged and ever since they were taking each other's medicines. She came for a follow-up today. Her husband and she are doing well now that they're back to their own medicines."
  9. Content Article
    NHS England is undertaking an audit of NHS specialised hospital services for patients with complications of mesh inserted for urinary incontinence and vaginal prolapse (Mesh Centres) and would like to hear from women who have had Mesh implanted. They'd like to hear from women who have had, or have considered having treatment for their Mesh complications, both surgical (mesh removal) and non-surgical treatment (including physiotherapy and pain management, for example). As part of the audit, Sally Cavanagh who works for NHS England was asked to team up with Kath Sansom from Sling The Mesh and Paula Goss from Rectopexy Mesh Victims & Support, to develop the survey. It is designed to capture feedback about how women reached the decision to seek, or not seek surgical Mesh removal, how they made their treatment decision and their experiences with health services and health staff involved in their treatment for complications of Mesh. The deadline to submit the survey is midnight Wednesday 11 October 2023.
  10. Content Article
    This is the first in a series of podcasts NHS England has produced to mark World Patient Safety Day 2023, and celebrate its theme of ‘engaging patients for patient safety’. The series features some of the Patient Safety Partners that work with the National Patient Safety Team, who play a vital role in providing a patient’s perspective to support our work to improve patient safety. In this podcast, Graham, who became a patient safety partner in 2020, shares his insights on the benefits of involving patients and why he feels it is so important in supporting the NHS to improve patient safety, and talks about his experience as a patient safety partner, particularly working to co-design elements of the medical examiner and medicines safety improvement programmes.
  11. Content Article
    Have you ever stopped and considered what the link is between the Patient Safety Incident Response Framework (PSIRF) and Hollywood? Probably not. Most likely, you have spent the summer of 2023 immersed in your organisation’s transition from the Serious Incident Framework (SIF) to PSIRF. Outside work, for those of us who are cinema-goers, our main Hollywood-related dilemma has revolved around which to watch first, Barbie or Oppenheimer? At the end of April 2023, we were offered the opportunity to present at the Health Care Plus conference, held at the EXCEL centre in London. Ours was the graveyard slot: Day 2 of the conference; 3.15 pm. The time when, quite understandably, the conference participants attentional capacity is usually waning. How could we encourage participants to stay the distance? How do you make a graveyard slot at the end of a two-day conference engaging?  More importantly, how do you rise to that challenge when the topic is implementing PSIRF? Our solution? Bring in Hollywood. Make PSIRF glamorous. Our blog shares what we presented: ‘PSIRF: The Hollywood Edit'. Unifying key messages from NHS England’s PSIRF guidance (NHS England, August 2022) with Hollywood movie titles and a bit of what we have learnt and reflected on along the way. 
  12. News Article
    A woman who died during an operation for a buttock enlargement in Turkey was not given enough information to make a safe decision about the procedure, a coroner has concluded. Melissa Kerr, 31, from Gorleston, Norfolk, died at the private Medicana Haznedar Hospital in Istanbul, in 2019. Ms Kerr had gone abroad to have what is commonly referred to as a Brazilian butt-lift or BBL, the Norwich inquest heard. The inquest was told Brazilian butt-lift operations carried the highest risk of all cosmetic surgery procedures. The UK has an agreed moratorium on carrying out such operations due to the dangers involved, expert witness and plastic surgeon Simon Withey said in a report for the inquest. Mr Withey said if the risk of the procedure had been explained to Ms Kerr before she had financially committed to the procedure she would not "in all probability" have gone through with it. Coroner Jaqueline Lake said she would be writing a report for the health secretary to try and prevent further deaths from this "risky" procedure. She said she was "concerned patients are not being made aware of the risks or the mortality rate associated with such surgery". She added, while the UK government had no control over what happens in other countries, "the danger to citizens who continue to travel abroad for such procedures continues... and I'm of the view future deaths can be prevented by way of better information". Read full story Source: BBC News, 12 September 2023
  13. News Article
    A high-profile government climbdown which legalised a type of cannabis medicine on the NHS five years ago misled patients, campaigners say. It was thought the law change would mean the unlicensed drug, which treats a range of conditions, could be freely prescribed by specialist doctors. But fewer than five NHS patients have been given the medicine, leaving others to either pay privately or miss out. The government says safety needs to be proven before a wider rollout. Legalisation of whole-cannabis medicine was hailed as a breakthrough for patients - giving either NHS or private specialist doctors the option to prescribe it if they believed their patients would benefit. But patients are being turned away, say campaigners, because doctors often do not know about the medicine, which is not on NHS trusts' approved lists. Some specialists who do know about it say there is insufficient evidence of the drug's safety and benefits to support prescribing. Senior paediatric consultant Dr David McCormick, from King's College Hospital in London, says it was "disingenuous" of the government to suggest in 2018 that NHS prescribing was ready to take place. "Parents were clamouring at our door, or phoning all the time, as they believed we were able to prescribe and that was not the case. "The message went out, 'doctors can now prescribe cannabis products' and that put us in a difficult position, because in truth we need to apply for that to be approved by NHS England." Read full story Source: BBC News, 13 September 2023
  14. Content Article
    A patient safety partner (PSP) is actively involved in the design of safer healthcare at all levels in the organisation. This includes roles in safety governance – e.g. sitting on relevant committees to support compliance monitoring and how safety issues should be addressed and providing appropriate challenge to ensure learning and change – and in the development and implementation of relevant strategy and policy. NHS England has provided a description of the Patient Safety Partner role.
  15. Content Article
    A Patient Safety Partner is someone who works with the NHS to make care safer for patients. This easy to read guide explains how important it is for the NHS that patients and carers are involved in making patient care safe.
  16. Content Article
    The results of the latest annual survey of hospital inpatients published by the Care Quality Commission (CQC) show patient satisfaction levels have remained largely static since 2021, but indicate a longer term decline in most areas compared to previous years.People were eligible to take part in the survey if they stayed in hospital for at least one night during November 2022 and were aged 16 years or over at the time of their stay.The survey highlights growing frustration with waiting times and reveal that four in ten people scheduled for planned treatment said their health deteriorated while waiting to be admitted.An A-Z list of inpatient survey results by NHS trust can be found here.
  17. News Article
    A trust facing a police investigation into one of the NHS’s largest ever maternity scandals is no longer rated ‘inadequate’ by the Care Quality Commission in its well-led and maternity domains. Nottingham University Hospitals Trust was rated “inadequate” for its leadership and maternity services during inspections in 2021 and 2022, following serious care failings exposed by staff and patients during this period. The Nottinghamshire police confirmed last week they were opening an investigation. But the regulator noted improvements after its well-led and maternity inspections which took place in April and June. The well-led rating has gone up from “inadequate” to “requires improvement” and maternity services at both hospitals have also gone up to “requirements improvement”. Greg Rielly, CQC deputy director of operations in the Midlands, said: “During this inspection, we saw a team that consistently led with integrity who were open and honest in their approach.” However, he stressed that while the culture across the trust was improving, some staff still didn’t feel able to raise concerns without fear of retribution. “Leaders were aware of this and were working to create a workplace that is free from bullying, harassment, racism, and discrimination so we hope to see an improved picture soon,” he said. Read full story (paywalled) Source: HSJ, 13 September 2023
  18. News Article
    MPs will investigate the sexual harassment and sexual assault of female surgeons taking place within the NHS. BBC News reported women being sexually assaulted even in the operating theatre, while surgery took place. And the first major report into the problem found female trainees being abused by senior male surgeons. The Health and Social Care Committee said it would look into the issue and its chair, Steve Brine, said the revelations were "shocking". "The NHS has a duty to ensure that hospitals are safe spaces for all staff to work in and to hold managers to account to ensure that action is taken against those responsible," Mr Brine said. "We expect to look into this when we consider leadership in the NHS in our future work." Read full story Source: BBC News, 13 September 2023
  19. Content Article
    In 2008, five ‘serious untoward incidents’ occurred on a small maternity unit in a hospital in the UK. The prevailing view, held by clinical staff, hospital managers, and executives, was that these events were unconnected and did not signal systemic failures in care. This view was maintained by the testimony of staff and governance procedures which prevented the incidents from being considered together. Drawing on the inquiry report of the Morecambe Bay Investigation (2015), Dawn Goodwin examines how the prevailing view was built and dismantled, eventually being replaced with a very different description of events. Overturning this view required affected parents to engage with governing bodies and legal processes, challenge clinical staff, lobby for inquests, and mobilise social media and the national press. Tracing how different descriptions of events weaken or gather force as they travel through different forums, processes, and are presented to different audiences, she explores the sociology of knowledge around establishing failures of care.
  20. Content Article
    According to the UK Sepsis Trust, sepsis affects 245,000 people every year in the UK alone, and 48,000 people die of sepsis-related illnesses. Sepsis arises when the body’s response to an infection injures its own tissues and organs. It may lead to shock, multi-organ failure, and death – especially if not recognised early and treated promptly. At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. We have pulled together six useful resources about sepsis that have been shared on the hub. They include advice on recognising and managing sepsis along with educational materials.
  21. Content Article
    Community hospitals play a very important role in supporting patients but, unlike with larger hospitals, little has been known until now about how they struggle with delayed discharges. Following a freedom of information request, the Nuffield Trust reveals the number of patients experiencing delays leaving community hospitals, and highlights the capacity challenges such hospitals face.
  22. Content Article
    Event analysis is a valuable tool to improve patient safety and quality of care by identifying root causes of incidents and implementing corrective actions to prevent future similar events from occurring. When we analyse adverse events in healthcare and do not incorporate an equity lens, however, we are missing a crucial piece of the investigative puzzle. Health equity is essential to improving health and well-being and can be costly if not addressed as explained in this Institute for Healthcare Improvement (IHI) blog
  23. Event
    To celebrate World Patient Safety Day, PAHO will hold a virtual seminar that will bring together patients, decision makers, health teams, and academics to discuss and share their experiences and reflections on how to increase patient and family participation in improving the quality and safety of health care. Further information and registeration
  24. Content Article
    One in three medical students plan to quit the NHS within two years of graduating, either to practise abroad or abandon medicine altogether, according to a survey published in BMJ Open. Poor pay, work-life balance and working conditions of doctors in the UK were the main factors cited by those intending to emigrate to continue their medical career. The same reasons were also given by those planning to quit medicine altogether, with nearly 82% of them also listing burnout as an important or very important reason. The findings from the study of 10,486 students at the UK’s 44 medical schools triggered calls for action to prevent an exodus of medical students from the NHS.
  25. Content Article
    A global shortage of an estimated 18 million health workers is anticipated by 2030, a record 130 million people are in need of humanitarian assistance, and there is the global threat of pandemics such as COVID-19. At least 400 million people worldwide lack access to the most essential health services, and every year 100 million people are plunged into poverty because they have to pay for healthcare out of their own pockets. There is, therefore, an urgent need to find innovative strategies that go beyond the conventional health-sector response. WHO recommends self-care interventions for every country and economic setting as critical components on the path to reaching universal health coverage (UHC), promoting health, keeping the world safe and serving the vulnerable.
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