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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Do you know the science behind what works and doesn’t work when it comes to keeping people safe in your organisation? Each week join Dr Drew Rae and Dr David Provan from the Safety Science Innovation Lab at Griffith University as they break down the latest safety research and provide you with practical management tips.
  2. Content Article
    Patient feedback on diagnostic errors may improve the quality and safety of care. This analysis examined patient feedback on what went well with the diagnostic process. Results mirrored those of studies on diagnostic errors, stating feeling heard, appreciated, and timely communication contributed to a good diagnostic process.
  3. Content Article
    This guide is for trusts who have an electronic patient record system (EPR) already in place and want to realise the transformational opportunities it presents. It focuses on the role of the board in leading these changes. In December 2022, NHS England estimated that over 85% of trusts in England had some form of EPR and set a target for EPRs to be implemented in at least 90% of trusts by December 2023. A well implemented and optimised EPR improves patient safety, staff satisfaction, patient flow and data quality. But this can only be achieved with continuous optimisation and investment. A poor EPR implementation, followed by a lack of investment in its ongoing development, can frustrate staff and create disillusionment. This in turn leads to poor usage and unsafe workarounds. In time this will negatively impact productivity and result in substandard data informing clinical decision making. If you are part of an integrated care system (ICS) looking to share or align EPRs across a number of organisations, this guide will also help you consider issues of convergence, scale and shared governance. It does not address procurement and implementation.
  4. Event
    There is currently remarkable consensus across think tanks, institutions, and political parties that a move towards a preventive state is key to creating a healthier nation. A preventive approach can help people live healthily for longer while also addressing many of the problems within the health and care system, allowing for proactive population health management and tackling of health inequalities. Creating a healthier nation needs a collaboration between people, places, the NHS, and businesses, as well as government. If the new government wants to improve the health of the nation, it should create an approach to health that spans all government departments, includes actions to reduce health inequalities, and implements measures that help people to make healthier choices. At this in-person event, the case is presented for how prevention can create a healthier nation, why it is particularly important now, and propose tangible actions for making this shift at the national, system and local levels. Join the King's Fund to understand why prevention is key to supporting healthier lives and how it can be made a reality. Join leaders and experts from across health and care, thinks tanks and politicians to explore: why moving towards a preventive state is particularly important now given the context of widening health inequalities and stalling of life expectancy how to make the shift to prevention a reality at national, system, and local levels the importance of measuring preventive expenditure the role of prevention when taking a population health approach the link between health and housing and how healthier communities can support a wider approach to prevention. how place-based approaches to prevention are key. Register
  5. Content Article
    Sohier Elneil, surgeon, expert in women’s pain, and founder of the first NHS vaginal mesh removal centre, speaks to the Rebecca Coombes about fighting for better care for her female patients.
  6. News Article
    Dan Harrison, who had schizophrenia and psychotic delusions about his parents, had been sectioned ten days before he attacked his father. He was detained at Neath Port Talbot Hospital, run by the Swansea Bay University Health Board. During those ten days he received no treatment or medication. He escaped through a door being held open by a member of staff who was talking to someone else and immediately headed for the family home where he killed his father. The attack came after Dan's mother, Jane, and her husband repeatedly asked for help from mental health services as their son’s state of mind and behaviour deteriorated. They were refused. Last month Kirsten Heaven, assistant coroner for Swansea, recorded in a narrative verdict that there had been repeated failings by the Swansea University Health Board and local council. She said multiple system failures had contributed to Kim’s death and warned of more deaths if they were not addressed. Jane is speaking out now, with her son’s permission, after a Sunday Times investigation highlighted the scale of mental health-related killings in Britain. There have been at least 233 reported since 2020 and there have been repeated warnings about NHS services failing to provide crisis care. Read full story (paywalled) Source: The Times, 1 June 2024
  7. News Article
    Three more babies have died from whooping cough this year as cases continue to rise across the country, according to the UK Health Security Agency. Since January, there have been 4,793 confirmed cases of whooping cough, with 181 babies under the age of three months diagnosed with the illness. A total of eight babies have now died from whooping cough this year. Pregnant women have been urged to get the whooping cough vaccine in order for their babies to be protected before they are old enough to receive the vaccine themselves. Babies can first be vaccinated against the disease when eight weeks old, while pregnant women are advised to get the vaccine at 16 and 32 weeks. Dr Gayatri Amirthalingam, a consultant epidemiologist at UKHSA, said: “Our thoughts and condolences are with those families who have so tragically lost their baby. “With whooping cough case numbers across the country continuing to rise and sadly the further infant deaths in April, we are again reminded how severe the illness can be for very young babies. “Pregnant women should have a whooping cough vaccine in every pregnancy, normally around the time of their mid-pregnancy scan (usually 20 weeks). This passes protection to their baby in the womb so that they are protected from birth in the first months of their life when they are most vulnerable and before they can receive their own vaccines. “The vaccine is crucial for pregnant women, to protect their babies from what can be a devastating illness.” Read full story Source: The Guardian, 6 June 2024
  8. Content Article
    From 1 April 2009 to 31 March 2019, NHS Resolution were notified of 631 clinical negligence claims relating to surgical burns to patients. Out of these 631 claims, 459 were settled, 58 were unmeritorious and 114 are still open. This has led to NHS Resolution paying £13.9m in damages and legal costs on behalf of NHS organisations.
  9. Content Article
    Reducing social inequalities in health and health determinants, including physical activity (PA), is a major challenge for public health. PA-promoting interventions are increasingly implemented. Little is known, however, about the impact of these interventions on social inequalities. For prioritising interventions most likely to be effective in reducing inequalities, studies of PA interventions need to conduct equity impact assessments. The aim of this article is to describe the development of a logic model framework for equity impact assessments of interventions to promote PA. The framework was developed within the prevention research network AEQUIPA—Physical activity and health equity: primary prevention for healthy ageing, informed by an equity-focused systematic review, expert interviews, exploratory literature searches, and joint discussions within the network. The framework comprises a general equity-focused logic model to be adapted to specific interventions. The intervention-specific equity-focused logic models illustrate the key elements relevant for assessing social inequalities in study participation, compliance with and acceptance of interventions, as well as the efficacy of interventions. Equity impact assessments are beneficial for prioritising interventions most likely to be effective in reducing health inequalities.
  10. Content Article
    Design creativity describes the process by which needs are explored and translated into requirements for change. This chapter examines the role of design creativity within the context of healthcare improvement. It begins by outlining the characteristics of design thinking, and the key status of the Double Diamond Model. It provides practical tools to support design creativity, including ethnographic/observational studies, personas and scenarios, and needs identification and requirements analysis. It also covers brainstorming, Disney, and six thinking hats techniques, the nine windows technique, morphological charts and product architecting, and concept evaluation. The tools, covering all stages of the Double Diamond model, are supported by examples of their use in healthcare improvement. The chapter concludes with a critique of design creativity and the evidence for its application in healthcare improvement.
  11. News Article
    One out of every six people have symptoms when they stop taking antidepressants - fewer than previously thought, a review of previous studies suggests. The researchers say their findings will help inform doctors and patients "without causing undue alarm". The Lancet Psychiatry review looked at data from 79 trials involving more than 20,000 patients. Some had been treated with antidepressants and others with a dummy drug or placebo, which helped researchers gauge the true effect of withdrawing from the drugs. Some people have unpleasant symptoms such as dizziness, headache, nausea and insomnia when they stop taking antidepressants, which, the researchers say, can cause considerable distress. Previous estimates suggested antidepressant discontinuation symptoms (ADS) affected 56% of patients, with almost half of cases classed as severe. But this review, from the Universities of Berlin and Cologne, estimates one out of every every six or seven patients can expect symptoms when stopping antidepressants and one in 35 will have severe symptoms. Read full story Source: BBC News, 6 June 2024
  12. Content Article
    Uncontrolled sensory stimuli can hinder healthcare delivery quality in trauma rooms. High noise and temperature levels can increase staff stress and discomfort as well as patient discomfort. Conversely, proper lighting can decrease staff stress levels and reduce burnout. Sensory overload in trauma rooms is a crucial concern, but no studies have been conducted on this issue.
  13. Content Article
    Diagnostic management teams (DMT), which are comprised of experts in specialised fields, review patient cases and produce reports with diagnostic interpretations and recommendations for future testing or treatments. This pre/post study evaluates the effectiveness of a coagulation DMT at one hospital. Cases reviewed by the DMT were twice as likely to have a diagnostic conclusion (i.e., ruled in or ruled out coagulopathy) than cases without DMT.
  14. News Article
    The United State's largest nurses union is demanding that artificial intelligence tools used in healthcare be proven safe and equitable before deployment. Those that aren’t should be immediately discontinued, the union says. Few algorithms, if any, currently meet their standard. “These arguments that these AI tools will result in improved safety are not grounded in any type of evidence whatsoever,” Michelle Mahon, assistant director of nursing practice at National Nurses United, told Fierce Healthcare. NNU represents 225,000 nurses in the US and has a presence in nearly every state through affiliated organisations, like the California Nurses Association, which protested the use of AI in healthcare in late April. NNU nurses also represent nearly every major hospital and health system in the nation. Most AI nurses interact with is integrated into electronic health records and is often used to predict sepsis or determine patient acuity, union nurses said at an NNU media briefing last month. EHRs cause an estimated 30,000 deaths per year, which is the third leading cause of death in the nation, Mahon said. Adding what they call “unproven” algorithms to EHRs is not how the health system should be spending dollars, NNU says. The union is demanding that all AI used in healthcare meet the precautionary principle, a philosophical approach that requires the highest level of protection for innovations without significant scientific backing. Any AI solution that does not meet this principle, which NNU claims is most of the AI currently on the market and deployed in hospitals, should be immediately discontinued, they say. Read full story Source: Fierce Healthcare, 3 June 2024
  15. Content Article Comment
    An email sent to Patient Safety Learning. The sender wishes to remain anonymous. "I am a patient in the Heart Failure Clinic at a London hospital. I am also a patient at a GP surgery which is a mere ten minutes from hospital. Yet, their computers cannot communicate with each other as they are different hospital trusts. Ridiculous. Therefore, my GP rarely knows about my clinic meetings in Cardiology, does not know the meds if they are altered, etc. etc. I do not get reports, or test results, either. A cloud of darkness. I asked PALS to send some test results to my GP surgery and they did, but I think it is a one-off. I had (have) to keep ringing the nurse specialist helpline or the Consultant's secretary for information. Meantime, messages from MyChart arrived in droves, all telling me my appointment letters and test results were there, awaiting me. However, when I logged in (numerous times) - there was never anything at all. No letters, test results, zilch, nothing. I, finally, managed to cancel the not-working MyChart. I have multiple medical problems and am 90 years old. Fortunately, I can work my computer, use the telephone and get to appointments. However, it is stressful and tiring to have to be ever alert because there is an accident waiting to happen. Software is not new. Computers arrived in the eighties. Who are the idiots who put these systems together but forgot to hook them up?"
  16. News Article
    Major hospitals in London have declared a critical incident after a cyber attack led to operations being cancelled and patients being diverted elsewhere for care. NHS officials said they were working with the National Cyber Security Centre after the attack on Synnovis, which provides pathology services to large hospitals and GP surgeries in the capital. The company said the ransomware attack has affected all of its IT systems, which has impacted its pathology services. Some procedures and operations have been cancelled or have been redirected to other NHS providers as hospital bosses continue to establish what work can be carried out safely. Synnovis was the victim of a ransomware cyberattack. This has affected all Synnovis IT systems, resulting in interruptions to many of our pathology services. Mark Dollar, Synnovis chief executive Health service leaders said there has been a “significant impact” King’s College Hospital, Guy’s and St Thomas’ – including the Royal Brompton and the Evelina London Children’s Hospital – and GP services in south-east London. A memo to staff said the “critical incident” has had a “major impact” on the delivery of services, with blood transfusions particularly affected. Patients have described last-minute cancellations to operations and blood tests. Read full story Source: The Independent, 4 June 2024
  17. News Article
    The negotiation of a pandemic accord intended to prevent the global disaster seen during Covid-19 should be completed in the next year, WHO have announced. “The amendments to the international health regulations will bolster countries’ ability to detect and respond to future outbreaks and pandemics by strengthening their own national capacities and coordination between fellow states, on disease surveillance, information sharing, and response,” said WHO’s director general, Tedros Adhanom Ghebreyesus. “This is built on commitment to equity, an understanding that health threats do not recognise national borders, and that preparedness is a collective endeavour.” The revised international health regulations includes a commitment to strengthening access to medical products and financing, and stronger, more precise language that should accelerate the detection of health threats and the necessary global action to manage them. “Full implementation of the international health regulations brings the world closer to being safer from pandemic threats. A new pandemic agreement with equity at its heart would further strengthen the rules around and guide international collaboration,” said Helen Clark, former New Zealand prime minister and co-chair of the Independent Panel for Pandemic Preparedness and Response. Read full story Source: BMJ, 4 June 2024
  18. News Article
    A record number of people in England were diagnosed with gonorrhoea last year, annual UK Health Security Agency figures show. Diagnoses rose 7.5% - from 79,268 in 2022 to 85,223 in 2023. Syphilis, meanwhile, rose 9.4% - from 8,693 to 9,513, the highest number since 1948 - with more heterosexual men and women becoming infected. Overall, sexually transmitted infection diagnoses, including several different STIs, rose 4.7%. The British Association of Sexual Health and HIV said the rise in STIs was a “concerning indicator” of pressure on sexual-health services and called for a new strategy. President Prof Matt Phillips said: “We find ourselves at a critical point for securing the viability of sexual-health services. “From recruitment challenges, to public-health funding, to ensuring the right experts are supporting every clinic, the next government has an opportunity to change the tides and address these barriers, to ensure everyone has timely access to expertise to support good sexual health and wellbeing.” Read full story Source: BBC News, 4 June 2024
  19. Content Article
    Ambulance handover delays arise when emergency departments become overcrowded as patients waiting prolonged periods for admission occupy clinical cubicles designed to facilitate the assessment and treatment of emergency arrivals. In response, many organisations become reliant on temporarily lodging acutely unwell patients awaiting admission in undesignated areas for care such as corridors, to provide additional space. This results in a significant risk of avoidable harm, indignity and psychological trauma for patients and has a negative effect on the well-being of healthcare professionals, since unacceptable standards of care become normalised.
  20. News Article
    A major health system’s pathology IT has been hit by a cyber attack, HSJ understands. A letter sent by Guy’s and St Thomas’ Foundation Trust chief executive last night said his £2.5bn-turnover trust was unable to connect to the servers of Synnovis. The problem is ongoing, and several senior sources told HSJ the system had been the victim of a ransomware attack. One said gaining access to pathology results could take “weeks, not days”. As well as GSTT – the NHS’s largest provider – neighbouring King’s College Hospital FT, which runs several hospitals in the system, and is thought to be affected. Synnovis also provides pathology services for primary care across all six of south east London’s boroughs. The news would make it one of the largest critical NHS systems brought down by a cyber attack. Read full story (paywalled) Source: HSJ, 4 June 2024
  21. Content Article
    A decision was taken by the Minister for Health, Robin Swann MLA, to establish a statutory public inquiry following the lookback review of urology patients (January 2019 until May 2020) initiated by the Southern Health and Social Care Trust. These concerns were related to Mr Aidan O’Brien, Consultant Urologist employed within the Southern Trust. Terms of Reference Key documents, the hearings and latest news on the Inquiry can be found on the Urology Services Inquiry website.
  22. Content Article
    In partnership with the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives, The Tommy’s National Centre for Maternity Improvement is working to prevent stillbirths and premature births across the UK. Our current method of assessing risk during pregnancy has remained unchanged since the 1970s, with midwives or doctors using a checklist to classify a woman as either ‘high’ risk or ‘low’ risk. The current system does not measure how high or low this risk is, and so does not allow for more personalised care. As a result, Tommy's National Centre for Maternity Improvement are creating The Tommy’s Pathway – an online medical tool that will help healthcare providers work out which pregnant women are most at risk of giving birth prematurely or of developing pregnancy complications that can lead to stillbirth. The Pathway will use information routinely gathered by midwives and doctors to provide a personalised risk score and treatment recommendations for every pregnant woman, ensuring that every woman receives the best support possible throughout pregnancy. The Pathway will also empower pregnant women to become more engaged in their own care.
  23. Content Article
    NHS England's annual report and accounts for the year ended 31 March 2023.
  24. Content Article
    Incivility or rudeness is a form of interpersonal aggression. Studies suggest that up to 90% of healthcare staff encounter incivility at work with it being considered ‘part of the job’. Interviews were undertaken between June and December 2019. Four themes were identified: paramedics reported a lack of respect displayed both verbally and non-verbally from other professional groups. The general public and interdisciplinary colleagues alike have unrealistic expectations of the role of a paramedic. In order to deal with incivility paramedics often reported taking the path of least resistance which impacts on ways of working and shapes subsequent clinical decision-making, potentially threatening best practice. Finally paramedics report using coping strategies to support well-being at work. They report that a single episode of incivility is easier to deal with but subsequent episodes compound the first. This study highlights the effect incivility can have on operational paramedics. Incivility from the general public and other health professionals alike can have a cumulative effect impacting on well-being and clinical decision-making.
  25. Event
    This training will support the development of expert understanding and oversight of systems based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries. WHO SHOULD ATTEND Executives, commissioning, & service managers supporting service lead investigator roles. The following only after attending the 2-day systems approach to patient safety incident response: All Executive, Commissioner and Service Leads for investigation; All Lead investigators conducting patient safety incident investigations investigators conducting. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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