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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Antimicrobial resistance (AMR) remains a global threat, which the Lancet is highlighting in a series of articles. This piece was written by a group of AMR survivors and their caregivers in order to share individual stories and perspectives on the impact of AMR. The authors highlight challenges in raising the profile of AMR, including insufficient funding, research, motivation and knowledge. They also call for meaningful patient engagement in the AMR agenda.
  2. News Article
    Families have warned a health board that more patients could die if lessons about poor mental health care are not learned. A report by the Royal College of Psychiatrists found less than half of 84 recommended improvements to a hospital trust’s mental health department have been made. In the past 10 years, four separate reviews have outlined changes to be implemented by Betsi Cadwaladr University Health Board. Patient watchdog Llais said people had continued to die during this time. At a meeting in Llandudno on Thursday morning, the health board, which runs the NHS in north Wales, apologised to families and said it was committed to improving. Problems with mental health services at the health board first became public in December 2013 when the Tawel Fan dementia ward at Ysbyty Glan Clwyd near Rhyl was closed. A report said elderly patients there were treated "like animals in a zoo". Before that, the board was aware of problems at Hergest mental health unit at Ysbyty Gwynedd in Bangor. An investigation found a culture of bullying and low morale, which meant patient safety concerns were not addressed. During the meeting earlier, Phill Dickaty, who’s mother Joyce Dickety died on Tawel Fan in 2012, told the board families felt “let down again". "As things stand, despite the passage of time and false reassurances offered by BCUHB, the Tawel Fan families have a real and significant concerns over the lack of progress," he said. "Be it patient or otherwise, nobody should ever have to endure a situation like Tawel Fan and the atrocities that took place. As well as the disappointment felt at the lack of progress, the risk of history repeating itself again in the future weighs heavily in the minds of Tawel Fan families." Read full story Source: BBC News, 29 May 2024
  3. Content Article
    This webinar hosted by The Patients Association aimed to highlight the realities of life with a long-term condition. Four people who live with long-term health conditions shared what their day-to-day lives are like.
  4. Content Article
    In this Forbes article, Robert Pearl MD looks at how AI will affect the legal situation when a patient is harmed in healthcare. He highlights growing confidence and an increasing body of research that points to generative AI being able to outperform medical professionals in various clinical tasks. However, he outlines many questions that still remain about the legal implications of using AI in healthcare. He also argues that liability will become increasingly complex, especially in places where AI is being used without direct individual oversight.
  5. Content Article
    Safety-netting advice is information shared with a patient or their carer to help them identify the need to seek further help if their condition fails to improve or changes. In some instances, it is mandatory for pharmacists to give patients safety-netting advice. This article in the Pharmaceutical Journal provides advice for pharmacists on how they can provide this advice clearly and appropriately. The article explains the importance of safety-netting and when it is appropriate, describes elements to include when safety-netting and provides advice on how to adequately document advice given.
  6. Content Article
    This June marks nine years of Sling The Mesh, the campaign group set up by Kath Sansom after she was harmed by pelvic mesh surgery. In this blog, Kath reflects on the valuable support the group has offered thousands of people harmed by surgical mesh. She highlights the successes the group has achieved by coming together to raise public awareness and advocate for better regulation and support for patients. She also outlines the many issues still faced by people harmed by mesh surgery and describes how Sling The Mesh will continue to press for better informed consent, greater transparency and an effective redress system for harmed patients.
  7. Content Article
    In 2011, trainee paediatrician Hadiza Bawa-Garba was convicted of manslaughter over the death of six-year-old Jack Adcock. In this blog for the BMJ, medical law campaigner Jenny Vaughan looks at how the case has raised the issue of legal responsibility for care within a stretched medical system, for a whole generation of doctors.
  8. Content Article
    In 1990, 10-year-old Robbie Powell died due to undiagnosed Addison’s disease. Tragically, his death was preventable. Concerns that Robbie may have had Addison’s disease had been raised following a previous hospital admission and a diagnostic test requested, but this was not followed up or shared with his parents, Will and Diane. In the two weeks before Robbie died, Robbie was seen by five GPs on seven occasions, but his parents were consistently told that there was nothing seriously wrong with their son. Robbie’s father Will has worked for decades to uncover why his son died and how the doctors and organisations involved responded following Robbie’s death. In this long-read interview, Will describes the events that led to Robbie’s death and his subsequent fight for justice, including his role in the successful campaign which resulted in organisational legal duty of candour. He talks about the devastating impact that having the truth withheld continues to have on his family and other families. Will then outlines what needs to be done to better protect families and ensure they get the full truth when a child dies due to avoidable harm. Please note: readers may find the following content distressing.
  9. Content Article
    When GP practices have a patient who is violent or exhibiting behaviour that makes them fear for their safety, the patient should immediately be removed from the practice list. This guidance from the BMA explains how to do this as well as outlining the special allocation scheme (SAS), which provides primary care medical services in a secure environment to patients who meet the criteria. In the SAS, designated GP practices provide services to patients by appointment at specific locations and times as detailed in individually agreed contracts. Patients join the scheme after being immediately removed as a result of an incident that was reported to the police. It aims to protect GPs, practice staff and patients who have the right to be in the practice without fear of intimidating behaviour. 
  10. Content Article
    The National Association for Healthcare Security (NAHS) was formed in 1994 as a UK non profit-making professional organisation. The NAHS operates in a single national network and aims to support and enable healthcare provision through the delivery of professional security management; promoting and ensuring members are best placed and equipped to provide a safe and secure environment for their organisations staff, patients and visitors. This process ultimately enhances and improves staff wellbeing and the healthcare environment along with improving the quality of a patient’s treatment journey. The website includes a library of resources relating to security in healthcare settings.
  11. Content Article
    Accurate and accessible medical information is key to successful patient-centred care, which can be supported by the availability of easy-to-understand summaries of articles published in medical journals. In this short Lancet article, Mohamed Seghier of Khalifa University of Science and Technology, makes the case for plain language summaries that enable clinically useful research to be understood by the general public.
  12. Content Article
    This cohort study in JAMA Network Open aimed to determine whether US Food and Drug Administration (FDA) warnings to prevent prenatal exposure to valproic acid are associated with changes in pregnancy risk and contraceptive use. The study examined 165 772 valproic acid treatment episodes among 69 390 women and found that pregnancy rates during treatment remained unchanged during the 15-year study, and were more than doubled among users with mood disorder or migraine compared with epilepsy. Contraception use among users was uncommon, with only 22.3% of treatment episodes having a 1-day overlap of valproic acid and contraception use. The authors argue that these findings suggest a need to review efforts to prevent prenatal exposure to valproic acid, especially for clinical indications where risk of use during pregnancy outweighs therapeutic benefit and safer alternatives are available.
  13. Content Article
    This US cross-sectional study in JAMA Network Open aimed to find out whether there is a difference in reported inappropriate antipsychotic medication use between severely and less severely deprived neighbourhoods, and whether this difference is modified by greater total nurse staffing hours. The study included 10,966 nursing homes and found that nursing homes that fell below critical levels of staffing (less than three hours of nurse staffing per resident-day), were associated with higher inappropriate antipsychotic medication use among nursing homes in severely deprived neighbourhoods (19.2%) compared with nursing homes in less deprived neighbourhoods (17.1%). These findings suggest that addressing staffing deficiencies in nursing homes, particularly those located in severely deprived neighbourhoods, is crucial in mitigating inappropriate antipsychotic medication use.
  14. Content Article
    According to the United Nations Convention on the Rights of the Child, all children have the right to the highest attainable standard of health “without discrimination of any kind”. The UK has committed to upholding this right—but not all children in the UK are equally protected. Racism is a known risk factor for health in children, ranging from preterm birth and low birthweight, to major depression and asthma, and childhood is a vital period that can shape health throughout the life course. The authors of this Lancet article report on a roundtable discussion convened by Race & Health and the Race Equality Foundation in October 2023. The discussion focused on racism in the UK health system, with the aims of identifying key areas of exposure to racism in the UK health system for children, and the main barriers to uprooting racist structures and practices in the health system. The roundtable recommended the following immediate actions: Adopt a human rights-based approach that upholds children's rights to the highest attainable standard of health without discrimination and abolish policies that undermine these rights for minoritised children. Incorporate anti-racist health and research practice into the health system's functioning and commissioning, including by increasing engagement during decision making, and co-creation of processes, policies, and procedures with minoritised communities to foster greater trust. Integrate anti-racist training within health-care curricula to ensure that the next generation of health workers have the information and skills to recognise and combat racism in the health system. Embed professional accountability to uphold anti-racist principles and practice into the health system, including by embedding anti-racism within the annual appraisal process as a professional requirement. Ensure that data and evidence collected and valued by the health system incorporate the voices and inputs of communities, delivering epistemic justice. End structural discrimination in institutions and systems that shape children's interactions with the health system, including social care systems, and separate policing and prison systems from health care. Uphold equality, diversity, and inclusion commitments and funding and allocate funding to dismantle racism and white supremacy in the UK health system. Co-create anti-racist and anti-oppressive services with minoritised communities, providing a viable alternative to oppressive systems and structures.
  15. News Article
    A nine-year-old boy died of sepsis eight days after he was discharged from hospital with influenza and sent home with painkillers, an inquest has been told. Dylan Cope was admitted to Grange University Hospital in Cwmbran, South Wales, with abdominal pain but was discharged after a medic “dismissed any concern” about his appendix. Days later the boy had a ruptured appendix and sepsis diagnosed, and he died at the University Hospital of Wales in Cardiff on December 14, 2022. Read full story (paywalled) Source: The Times, 21 May 2024
  16. Content Article
    This Lancet study examines the discrepancy between occurrence of Long Covid as perceived and reported by participants in longitudinal population-based studies and evidence of Long Covid recorded in their EHRs. The authors argue that this discrepancy might reflect substantial unmet clinical need, particularly amongst patients of non-White ethnicity. This is in keeping with reports from individuals with Long Covid of difficulties accessing healthcare, and poor recognition of and response to their illness when they do.
  17. News Article
    Jersey politicians have voted to approve plans to allow assisted dying for those with a terminal illness "causing unbearable suffering". The States Assembly has been debating two routes through which people who have lived in Jersey for longer than a year, are 18 or over and have decision-making capacity could apply for assisted dying. A total of 32 members voted in favour while 14 voted against route one. The second route, for those who are not terminally ill but who have an incurable medical condition causing unbearable suffering, was rejected by a majority of 27 to 19. Plans for legalising assisted dying were voted on in principle by the assembly in 2021, but the aim of the vote was to decide how it could work in practice. With a decision now made, the process for drafting a law could take about 18 months, with a debate then taking place by the end of 2025. If a law is approved, it is expected a further 18-month implementation period would then begin, meaning the earliest for it to come into effect would be summer 2027. Speaking after the debate, Chief Minister Lyndon Farnham said "robust safeguards" would be "enshrined in law." He thanked the assembly for a "thoughtful, respectful and considered" debate. Read full story Source: BBC News, 22 May 2024
  18. Content Article
    The last two decades have seen substantial advancement in the practice of team-based, safe care delivery. In parallel, burnout has been recognised as prevalent among US doctors and influenced by workplace structure and experiences. This study assessed US doctors’ perceptions of team-based care delivery and safety climate within their institutions and how these domains were associated with burnout.
  19. Event
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    Despite being one of the largest economies, the UK suffered the third worst Covid-19 death toll in Western Europe, largely due to entrenched inequalities that were exposed and worsened by the pandemic. The Unequal Pandemic film, executively produced by Debbie Abrahams MP and Good Guys Productions, draws to light the disproportionate impact of the pandemic on marginalised communities. This pre-release screening and panel event, created in collaboration with Covid-19 Bereaved Families for Justice UK and UCL, provides an opportunity for policy makers, bereaved families, experts and all with an interest in protecting lives in the future, to take stock of what went wrong, and what can and must be done to make sure the UK is better prepared when the next pandemic hits. We hope this event will allow us to gather and learn from the experiences of experts, government workers and community members, and help us forge a practical path towards pandemic preparedness. Watch The Unequal Pandemic Film trailer. Chair Prof Ibrahim Abubakar, Pro-Provost (Health) at UCL and Dean for the Faculty of Population Health Sciences Speakers Prof Sir Michael Marmot, Director, UCL Institute of Health Equity Debbie Abrahams MP, Executive Producer of 'The Unequal Pandemic' Lobby Akinnola, Spokesperson for Covid-19 Bereaved Families for Justice UK whose personal story is featured in the film Prof Naomi Fulop, Professor of Health Care Organisation and Management, UCL and a Director, Covid-19 Bereaved Families for Justice UK
  20. News Article
    The number of people sent out of their home area for a mental health bed – in some cases hundreds of miles away – has increased to a five-year high, despite national ambitions to eliminate the practice. A 2021 date to stop “inappropriate out of area placements” was initially set by government and NHS England in 2016 but, despite initial reductions, the target was missed, with hundreds of patients still affected each month. Demand and bed pressures in the wake of covid appeared to make it more difficult and numbers have been rising. Analysis of the latest NHS Digital data this month shows 825 active inappropriate placements in February 2024 following a steady rise from December 2023, when there were 700 (see chart). The year on year increase from February last year is 15 per cent, but there has been a 46 per cent rise since a low of 565 just 14 months previously, in December 2022. Being sent out of area can disrupt the patient’s care, make it less likely patients will be visited, harder for them to return home and to community support, and is also often very expensive as places are bought at short notice from independent providers. NHSE acknowledged pressures on OAPs in 2024-25 planning guidance but asked systems to “work towards” eliminating them, saying they are “detrimental to patient safety, experience and outcomes.” National mental health director Claire Murdoch last month told HSJ they represented “poor care at relatively high costs.” Read full story (paywalled) Source: HSJ, 23 May 2024
  21. News Article
    Patients taking antidepressants are being warned to beware of side-effects that could leave them 'asexual' even after they stop using them - a problem that could affect millions of Brits. Selective serotonin reuptake inhibitors (SSRIs), the most common class of antidepressant drug in the UK, are relied upon by one in eight Brits - 8.6million in all - who are dealing with mental health issues like anxiety and depression. Common SSRIs prescribed in the UK include citalopram, fluoxetine and sertraline, sometimes known by brand names Cipramil, Prozac and Lustral - but their use has been linked to long-term and even permanent sexual dysfunction by researchers. The NHS has warned that side effects such as a loss of libido and achieving orgasm, lower sperm count and erectile dysfunction 'can persist' after taking them - and patients have described feeling 'carved out', relationships wrecked, from their use. Men and women say SSRI side-effects have hampered their sex lives, even after coming off of the medications - a condition known as Post-SSRI Sexual Dysfunction (PSSD), which is not officially recognised by UK health authorities. For millions, antidepressants can be a life-saving drug - but the authors of a US petition urging more warnings to be applied to the drugs say it can be 'impossible... to weigh the benefits of treatment against the harms'. Read full story Source: Daily Mail, 23 May 2024 Read this opinion piece on the hub by someone who suffers from post-SSRI sexual dysfunction (PSSD) after he was prescribed a selective serotonin reuptake inhibitor. The author calls for widespread recognition, improved risk communication and better support for sufferers. If you have experience of PSSD, you can also share your insights in our community discussion.
  22. Event
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    The session will explore the system wide risks involved in prescribing through reference to clinical negligence claims from NHS Resolution and the panel firm, Hill Dickinson. Event programme The invaluable role of pharmacists Common medicine error claims Recommendations Q&A panel discussion Contributors Joanne Hughes – Partner | Hill Dickinson Dr Anwar Khan – Senior clinical advisor | NHS Resolution Register for the webinar 20240703 Dispelling the myth-towards safer practice flyer.pdf
  23. Event
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    NHS Resolution’s Safety and Learning team, in collaboration with HSSIB and NHS England are hosting a virtual forum on the benefits of implementing safety science in primary care, responding to patient safety incidents and the support available to staff working in general practice and primary care. Event programme How claims data can support us | NHS Resolution Patient safety education offer and the role of HSSIB in primary care | Health Services Safety Investigations Body Primary care patient safety strategy | NHS England Q&A panel discussion Contributors Andrew Murphy-Pittock – Education director | Health Services Safety Investigations Body Dr Kiren Collison – Deputy medical director for primary care | NHS England Hester Wain – Head of patient safety policy | NHS England Samantha Thomas - National safety and learning lead for General Practice (Midlands and North) | NHS Resolution Register for the webinar Benefits in primary care webinar.pdf
  24. News Article
    Having an epidural during labour can reduce the risk of serious childbirth complications by 35%, according to research that suggests expanding access to the treatment may improve maternal health. An epidural is an injection in the back to stop someone feeling pain in part of their body. Making them more widely available and providing more information to those who would benefit from one was even more important than previously thought, researchers said. The study by the University of Glasgow and the University of Bristol involved 567,216 women who were in labour in Scottish NHS hospitals from 2007 and 2019, and went on to give birth vaginally or by an unplanned caesarean section. Of the total, 125,024 of the women had an epidural. Researchers analysed the rate of serious complications, including heart attacks, eclampsia, and hysterectomies during childbirth. Having an epidural cut the risk of these events by 35%, the study found. The lead author, Prof Rachel Kearns, of the University of Glasgow, said: “This finding underscores the need to ensure access to epidurals, particularly for those who are most vulnerable – women facing higher medical risks or delivering prematurely. “By broadening access and improving awareness, we can significantly reduce the risk of serious health outcomes and ensure safer childbirth experiences.” Read full story Source: The Guardian, 22 May 2024
  25. News Article
    Patients could be put at risk by plans to allow local NHS bodies to oversee the quality of health screening programmes for diseases such as breast and bowel cancer, experts have suggested. At the moment, NHS England runs the Screening Quality Assurance Service (SQAS) to make sure local organisations comply with national standards, are safe and can be subject to inspections. There are 11 national screening programmes in England, including those for breast, cervical and bowel cancer, plus antenatal and newborn screening, abdominal aortic aneurysm and diabetic eye screening. At the moment, screening programmes must report all safety incidents to the SQAS and the SQAS inspectors visit local sites to pick up urgent issues and make recommendations. Now, a report in the British Medical Journal questions plans by NHS England to allow local bodies to have more control. Sue Cohen, former national lead of screening quality assurance at Public Health England, told the BMJ that devolving responsibility for SQAS to local organisations would be a “retrograde” step. She pointed to previous issues, such as in Kent where a lack of oversight of a cervical screening programme led to women with cancer not being picked up. She said: “If you don’t have a quality assurance service that is properly resourced and has that ability to keep a national view, you will simply not have the oversight of the system and there is a bigger risk of incidents going undetected.” Read full story Source: Medscape News, 22 May 2024
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