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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Drug shortages are a chronic and worsening issue that compromises patient safety. Despite the destabilising impact of the Covid-19 pandemic on pharmaceutical production, it remains unclear whether issues affecting the drug supply chain were more likely to result in meaningful shortages during the pandemic. This study estimated the proportion of supply chain issue reports associated with drug shortages in the USA overall and with the Covid-19 pandemic. It found that supply chain issues associated with drug shortages increased at the beginning of the Covid-19 pandemic. Ongoing policy work is needed to protect US drug supplies from future shocks and to prioritize clinically valuable drugs at greatest shortage risk.
  2. Content Article
    Falls are reported by more than 14 million US adults aged 65 years or older annually and can result in substantial morbidity, mortality, and health care expenditures. This study reviewed interventions to reduce falls.
  3. Content Article
    Infections due to multidrug-resistant organisms (MDROs) are associated with increased morbidity, mortality, length of hospitalisation, and health care costs. Regional interventions may be advantageous in mitigating MDROs and associated infections. This study evaluated whether implementation of a decolonisation collaborative is associated with reduced regional MDRO prevalence, incident clinical cultures, infection-related hospitalisations, costs, and deaths. It found a regional collaborative involving universal decolonisation in long-term care facilities and targeted decolonisation among hospital patients in contact precautions was associated with lower MDRO carriage, infections, hospitalisations, costs, and deaths.
  4. Content Article
    The Global Strategy for Infection Prevention and Control (GSIPC) vision is that by 2030 everyone accessing and providing healthcare is safe from associated infections. The GPIPC outlines eight strategic directions, providing the guiding framework for country action plans. A Guide to Implementation is being developed to support countries in the development of their national action plans towards the 'vision of 2030'.
  5. News Article
    The NHS supply chain contains “absolutely massive” cybersecurity risks which have not “really been talked about”, an integrated care board and trust chair has warned. Lena Samuels, who is chair of two London trusts and of Hampshire and Isle of Wight Integrated Care Board, said: “We’ve been talking internally about our own organisations but we haven’t really talked about the supply chain and the risks within that – and that is absolutely massive.” Ms Samuels, speaking at the NHS Confed Expo conference yesterday, said many NHS organisations still needed to question: “How do our risk registers capture what our supply chain resilience looks like in terms of cyber protection?” She said NHS organisations also needed to be considering “who on my board is going to ask that question” and “whether they’re going to even think of asking that question”, adding: “There’s so much that we’ve got to think about.” Read full story (paywalled) Source: HSJ, 14 June 2024
  6. Content Article
    Managing medicines for someone can be a challenge, particularly if they're taking several different types. Although the person you care for may appreciate your support with their medicines, bear in mind that they have a right to confidentiality. It's up to them to decide how much of their health and medicines information is available to you as their carer, and how much you should be involved in their care. This NHS page gives tips on how to give pills correctly, dosette boxes and medicine reminders, asking for a structured medication review and medicine safety.
  7. News Article
    The owner of a group of privately-run children’s mental health hospitals is facing legal action by dozens of former patients, who claim they suffered inhuman and degrading treatement at the facilities. Hospitals formerly run by The Huntercombe Group face at least 54 individual clinical negligence claims, The Independent can reveal. Patients treated within several of the hospitals, now owned by Active Care Group, came forward to solicitors Hutchoen Law following several exposés by this publication, revealing allegations of “systemic abuse.” Documents submitted to Manchester Civil Court on Thursday before Judge Nigel Bird, who will decide if permission is be granted for claims to be brought, revealed allegations including: Assault and battery, relating to the inappropriate and unnecessary forced feedings and physical restraint. False imprisonment. Breaches of the Human Rights Act including prohibition of inhuman and degrading treatment. Read full story Source: The Independent, 13 June 2024
  8. News Article
    The mother of a 13-year-old girl who died of sepsis has said she hopes Martha’s rule, which gives patients and their families the right to a second medical opinion, will “upend” the “hierarchy” on hospital wards. Merope Mills, who campaigned with her husband, Paul Laity, to give families more say regarding care following the death of their daughter Martha, also called for a “mutual respect” between patients and doctors. More than 140 NHS sites in England have agreed to implement Martha’s rule, a patient safety initiative that will give patients and their families round-the-clock access to a rapid review by an independent critical care team from elsewhere in the hospital if they feel their health, or that of a family member, is deteriorating and they are not being listened to. Speaking at NHS ConfedExpo on Wednesday, Mills, an executive editor at the Guardian, said: “My big thing is, I think we need to be more equal. “It’s a very unequal place, a hospital ward, and there’s hierarchy and it’s very steep and it’s very strict. And, you know, when I first started talking about that, I sort of thought the nurses were at the bottom of the hierarchy. “And I refer to that because they didn’t feel that ability to speak up in Martha’s case. But I’ve actually come to realise that the people at the bottom of the hierarchy are the patients. “They are the ones with the least power and I just would like to upend that and just have a sense of mutual respect between doctor and patient.” Read full story Source: The Guardian, 14 June 2024
  9. News Article
    NHS England’s head of patient safety has suggested too much time and resource is being spent on “burdensome” inquiries to investigate failings in the system. Aidan Fowler said national chiefs want to see a shift away from “looking back 10 years and asking ‘what did we miss’”, and instead wants teams to be resolving problems in real time. At trusts where safety concerns have been highlighted, he said “people descend, and there are a lot of asks, and the pressure mounts, and they end up with an action list of hundreds of things, and it becomes very burdensome – we have to avoid that”. Speaking at a session at the NHS Confederation Expo event in Manchester this week, he encouraged organisations to report concerns early so NHSE can respond more quickly, supporting them and working through problems to prevent public inquiries from needing to happen in the first place. Mr Fowler added: “We have to get more proactive. We will spend less of our time in the future, is the plan, than we are now – doing what I call driving in the rear view mirror. “We don’t want to be looking back 10 years and asking, ‘what did we miss’, we want to be seeing things in real time… we don’t want to be spending our time in big inquiries into failings in the system.” Read full story (paywalled) Source: HSJ, 14 June 2024
  10. News Article
    Three staff have been put on “improvement plans” after a patient’s death which a coroner said nurses had been dishonest about, HSJ has learnt. North East London Foundation Trust was heavily criticised over the death of Winbourne Charles at an inquest last year. Coroner Graeme Irvine said staff “had not told the truth” about how Mr Charles came to take his own life in an inpatient unit at Goodmayes Hospital, in east London. Two witnesses refused to give evidence, citing a rule that they could not be compelled to incriminate themselves. Mr Irvine recorded a verdict of “suicide, contributed to by neglect, to which failures in medical intervention contributed and to which failures to respond to an obvious risk of self-harm contributed”. His prevention of future deaths report also noted “observation records appeared to have been created utilising a ‘cut and paste’ function” while there were “factually inaccurate entries” stating Mr Charles “was alive and well” up to two days after his death. In comments reported by the Barking and Dagenham Post last year, Mr Irvine said: “I think witnesses who have given evidence to me in this inquest have not told the truth. “It seems to me that this remarked upon a culture of impunity and that, unless someone sees there are consequences to their actions, nothing is going to change.” Read full story (paywalled) Source: HSJ, 14 June 2024
  11. Content Article
    On 11 April 2021 an investigation into the death of Winbourne Gregory Charles, aged 58, was carried out. Winbourne was admitted into hospital under section 2 of the Mental Health Act 1983 in November 2020 following an attempt to take his own life. In December 2020 on a diagnosis of depressive illness incorporating psychotic symptoms, Mr Charles was made subject to an order under section 3 of the Mental Health Act 1983. On 10 April 2021 Mr Charles was found unresponsive, suspended on the mental health ward. The Court returned a conclusion of:   “Suicide, contributed to by neglect, to which failures in medical intervention contributed and to which failures to respond to an obvious risk of self-harm contributed.”   Mr Charles’ medical cause of death was determined as 1a Suspension.
  12. Content Article
    Current adverse effects of medical treatment (AEMT) incidence estimates rely on limited record reviews and underreporting surveillance systems. This study evaluated global and national longitudinal patterns in AEMT incidence from 1990 to 2019 using the Global Burden of Disease (GBD) framework. It found that although the global population increased 44.6% from 1990 to 2019, AEMT incidents rose faster by 59.3%. The net drift in the global incidence rate was 0.631% per year. The proportion of all cases accounted for by older adults and the incidence rate among older adults increased globally. The high SDI region had much higher and increasing incidence rates versus declining rates in lower SDI regions. The age effects showed that in the high SDI region, the incidence rate is higher among older adults. Globally, the period effect showed a rising incidence of risk after 2002. Lower SDI regions exhibited a significant increase in incidence risk after 2012. Globally, the cohort effect showed a continually increasing incidence risk across sequential birth cohorts from 1900 to 1950.  As the global population ageing intensifies alongside the increasing quantity of healthcare services provided, measures need to be taken to address the continuously rising burden of AEMT among the older population.
  13. Content Article
    In most developed countries, substantial disparities exist in access to mental health services for black and minority ethnic (BME) populations. This study sought to determine perceived barriers to accessing mental health services among people from these backgrounds to inform the development of effective and culturally acceptable services to improve equity in healthcare. It found that people from BME backgrounds require considerable mental health literacy and practical support to raise awareness of mental health conditions and combat stigma. There is a need for improving information about services and access pathways. Healthcare providers need relevant training and support in developing effective communication strategies to deliver individually tailored and culturally sensitive care. Improved engagement with people from BME backgrounds in the development and delivery of culturally appropriate mental health services could facilitate better understanding of mental health conditions and improve access.
  14. Event
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    The Centre for Perioperative Care (CPOC) progresses a number of innovative and exciting collaborations with its patient facing partners since its origin in 2019. This webinar is designed to bring together lay and patient representation from both its Board and Advisory Group partners, as well as patient organisations and charities. The aim is to understand better the needs of patient and public engagement from a perioperative perspective. The webinar will include presentations from speakers investigating the Psychological and Behavioural science backgrounds of patients’ needs and wants, as well as patientvoices@RCOA. There will be an opportunity to develop these ideas in breakout groups to produce a consensus statement which CPOC will use to further develop the patient facing perioperative strategy. Considering the increasing waiting times that patients are having to process, while seeing their conditions potentially deteriorate, this is an opportunity to bring like-minded voices together to benefit patient outcomes within the UK. Further information
  15. Content Article
    Patient advocate and healthcare communications consultant, Tambre Leighn, shares her poster, Ask Me!: Transforming Patient Communication to Improve Enrollment & Adherence in Clinical Trials and Cancer Care, presented at the American Association of Cancer Researchers conference.
  16. Content Article
    This poster from presents preliminary data from a proof-of-concept examining the use of artificial intelligence technology, which can aid medical staff in locating, automatically reporting and effectively classifying safety incidents
  17. Content Article
    The Patient Safety Authority's 2023 Annual Report.
  18. Content Article
    Total parenteral nutrition (TPN, also known as PN) is a method of providing nutrition directly into the bloodstream to those unable to absorb nutrients from the food they eat. TPN is used in all age groups, but in babies its use is often as part of a temporary planned programme of nutrition to supplement milk feeds in those too immature to suckle or too sick to receive milk feeds as a result of intestinal conditions. TPN consists of both aqueous and lipid components, which are infused separately into the baby via specific administration sets and infusion pumps. The rate at which TPN is administered to a baby is crucial: if infused too fast there is a risk of fluid overload, potentially leading to coagulopathy, liver damage and impaired pulmonary function as a result of fat overload syndrome. In a recent three and a half year period 10 incidents were identified where infusion of the aqueous and/or lipid component of TPN at the incorrect rate resulted in severe harm to babies through pulmonary collapse, intraventricular haemorrhage or organ damage, and where intensive intervention and treatment were needed. Most of these incidents involved too rapid a rate of infusion.
  19. News Article
    An £8m prize for a breakthrough in the fight against superbugs has been awarded, after a decade-long search for a winner, to a test that can identify how to treat a urinary tract infection in 45 minutes. The test could herald a “sea change” in antibiotic use, the judges said as they announced the winner of the Longitude prize on antimicrobial resistance (AMR). AMR, where the drugs used to treat infections no longer work, is a growing concern. It leads to the deaths of nearly 1.3 million people worldwide annually and is predicted to cause 10 million deaths a year by 2050. Between 50% and 60% of women will experience at least one urinary tract infection (UTI) in their lifetime, and up to half of the bacteria that cause the infections are resistant to at least one antibiotic. The infections can cause potentially fatal sepsis. However, a lack of good, quick tests means doctors often have to diagnose an infection based on symptoms and guess which antibiotic will work. The inappropriate use of antibiotics drives resistance by giving bacteria opportunities to adapt to evade them. The winning Sysmex Astrego’s PA-100 AST system is based on technology from Uppsala University in Sweden. A 400-microlitre sample of urine is placed on a phone-sized cartridge and then into a shoebox-sized analyser unit. It can spot bacterial infection within 15 minutes, and identify the antibiotic to treat it within 45 minutes. Read full story Source: The Guardian, 12 June 2024
  20. News Article
    Hundreds of thousands of people are being forced to wait months to start essential cancer treatment, with deadly delays now “routine” and even children struck by the disease denied vital support, according to a series of damning reports. Health chiefs, charities and doctors have sounded the alarm over the state of cancer care in the UK as three separate studies painted a shocking picture of long waits and NHS staff being severely hampered by a worsening workforce crisis and a chronic lack of equipment. The first report, by Cancer Research UK, found that 382,000 cancer patients in England were not treated on time since 2015. The charity investigated how many patients had begun treatment 62 days or longer after being urgently referred for suspected cancer. The national NHS target – under which at least 85% of people should start treatment within 62 days – was last met in December 2015. The second report, by the Royal College of Radiologists (RCR), said delays in cancer care had become routine, with nearly half of UK cancer centres experiencing weekly delays in starting treatment. The RCR also warned of a “staggering” 30% shortfall in clinical radiologists and a 15% shortfall in clinical oncologists – figures it projects will get worse in the next few years. The third paper, from four children’s cancer charities – Young Lives vs Cancer, Teenage Cancer Trust, Ellen MacArthur Cancer Trust, and Children’s Cancer and Leukaemia Group – said young patients were being failed by a lack of support after diagnosis. Naser Turabi, the charity’s director of evidence, said the crisis was causing widespread treatment delays that “negatively impact” patients. “One study has estimated that a four-week delay to cancer surgery led to a 6-8% increased risk of dying, and delays can also reduce the treatment options that are available. There are also the psychological effects – with waiting causing major stress and anxiety for cancer patients and their loved ones.” Read full story Source: The Guardian, 13 June 2024
  21. Content Article
    Cancer Research UK has published a manifesto that sets out the measures and commitments the next government can make to help prevent 20,000 cancer deaths every year by 2040.
  22. Content Article
    The Royal College of Radiologists (RCR) have published their 2023 clinical radiology and clinical oncology workforce census reports. These reveal dangerous shortages of doctors essential in the diagnosis and treatment of cancer, and other conditions including stroke.  
  23. Content Article
    Do you ever forget what you want to ask when you meet with a healthcare professional? Do you leave your appointment without answers to all your questions? To avoid this, the guide will help you to prepare, by giving you advice on what you might want think about before your consultation. You can also use it as a reminder or prompt and it is handy for making notes after your consultation. The main aim of this guide is to empower you, by taking control of your healthcare (or the healthcare of the person you look after), in partnership with your healthcare professional. Preparing information before your consultation and taking it with you will make sure the time you spend with your doctor, pharmacist or practice nurse is used as effectively as possible.
  24. Content Article
    Four of the UK’s leading children’s and young people’s cancer charities, Young Lives vs Cancer, Teenage Cancer Trust, Ellen MacArthur Cancer Trust, and Children’s Cancer and Leukaemia Group (CCLG), have launched The North Star, an ambitious vision for a better future for children and young people with cancer. In 2022, the charities, together with Dartington Service Design Lab, began an in-depth programme of qualitative and quantitative research, with the aim to transform cancer care for children and young people. This evidence base, which includes the lived experience of over 1,500 young people, parents, carers and siblings, now provides the foundation to develop solutions and inform decisions that achieve greater outcomes for young people and their families affected by cancer. This report focuses on the needs and wellbeing of children and young people with cancer and their families and identifies the gaps in support and areas which need vital transformation.
  25. Content Article
    The United States continues to have the highest rate of maternal deaths of any high-income nation, despite a decline since the Covid-19 pandemic. And within the U.S., the rate is by far the highest for Black women. Most of these deaths — over 80% — are likely preventable. With policies and systems in place to support women during the perinatal period, several high-income countries report virtually no maternal deaths. As policymakers and health care delivery system leaders in the U.S. seek ways to end the nation’s maternal mortality crisis, these countries may offer viable solutions. This brief updates an earlier Commonwealth Fund study of differences in maternal mortality, maternal care workforce composition, and access to postpartum care and social protections between the U.S. and other high-income countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. In this edition, we have also included data on Chile, Japan, and Korea — all high-income countries with universal healthcare systems.
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