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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    There is widespread variation in the instance and quality of meaningful patient involvement across the 42 Integrated Care Systems (ICSs) of NHS England. This is seen throughout the structures, policies and processes of the ICSs, from the omission of patient representatives on decision-making bodies—such as Integrated Care Boards (ICBs)—to the neglect of clear consultation when decisions are made concerning a patient’s care. This report present the results of research and analysis conducted by the Medical Technology Group (MTG). It shows that where a patient lives is the biggest determinant to whether they are involved in their care meaningfully, or at all. It makes recommendations for the Government, NHS England and ICS's on the approach that should be taken to ensure meaningful patient engagement.
  2. Content Article
    Patients and families are key partners in diagnosis, but there are few methods to routinely engage them in diagnostic safety. Policy mandating patient access to electronic health information presents new opportunities, and in this study, researchers tested a new online tool—OurDX—that was codesigned with patients and families. The study aimed to determine the types and frequencies of potential safety issues identified by patients with chronic health conditions and their families and whether their contributions were integrated into the visit note. The results showed that probable Diagnostic Safety Opportunities (DSOs) were identified by 7.5% of paediatric and adult patients with underlying health conditions or their families. Among patients reporting diagnostic concerns, 63% were verified as probable DSOs. The most common types of DSOs were patients or families not feeling heard, problems or delays with tests or referrals and problems or delays with explanation or next steps. In chart review, most clinician notes included all or some patient/family priorities and patient-reported histories. The researchers concluded that OurDX can help engage patients and families living with chronic health conditions in diagnosis. Participating patients and families identified DSOs and most of their OurDX contributions were included in the visit note.
  3. Content Article
    The Trade Unions Congress (TUC) is proposing a new care workforce strategy for England, developed with trade unions and informed by the voice and experiences of care workers. This strategy document sets out the critical building blocks to ensure care workers are valued and supported, as a key means of addressing the current staffing crisis and improving access to and quality of social and childcare services.
  4. Content Article
    Leadership within the NHS has never been more critical. The need to support staff, remain resilient to the ongoing operational challenges create space to develop services which are locally responsive and inclusive are all pre-requisites for organisational success. However, for every leader there is also the need to know when it is time to move on, and the system can make that easier (or harder) to recognise and to act on. In this blog for BMJ Leader, Aqua’s Chief Executive Sue Holden looks at the issues facing senior NHS leaders who are having to function in ever-changing structures and a shifting culture. She asks whether innovative approaches to roles and contracts would allow the NHS to retain their skills and experience, while allowing new leaders to come through to senior positions.
  5. Content Article
    This is one of a series of 'Learning from safety incidents' resources published by the Care Quality Commission (CQC). Each one briefly describes a critical issue—what happened, what the CQC and the provider have done about it, and the steps you can take to avoid it happening in your service. This edition is about ensuring the safety of people using wheelchairs in health and social care. The CQC recently prosecuted a care home provider for exposing someone using their service to a significant risk of avoidable harm, which resulted in a life-changing injury.
  6. Content Article
    Learn Together is a resource website that equips patients and families with the knowledge and resources to be involved effectively in patient safety investigations. The resources have been designed, together with people who have experienced patient safety incidents and investigations, to provide the information and support patients might need following a patient safety incident. Information is provided in a range of formats including downloadable guides, videos and infographics. The site also provides information and resources for engagement leads. Learn Together is a partnership between Sheffield Hallam University, the University of Leeds, Bradford Teaching Hospitals NHS Foundation Trust, Bradford District Care NHS Foundation Trust, Leeds and York Partnership NHS Foundation Trust and York and Scarborough Teaching Hospitals NHS Foundation Trust, and is funded by the National Institute for Health and Care Research (NIHR).
  7. Content Article
    In this article for Health Services Insight, NHS consultant David Oliver examines why most comments on articles in the Health Services Journal (HSJ) are posted anonymously. He highlights that this tendency towards anonymity from commenters who are clearly in influential, senior NHS posts, indicates that the culture in the NHS management community, from NHS England down, is one that makes most people fearful of saying anything in their own name in case of reprisal. He also points out that a culture where people are afraid to make comments and criticisms in their own name is in conflict with the Nolan Principles of 'selflessness', 'integrity', 'objectivity', 'accountability', 'openness', 'honesty' and 'leadership' that senior NHS managers and officials are supposed to be guided by.
  8. Content Article
    In the wake of the conviction of Lucy Letby, a neonatal nurse who has been found guilty of the murder of seven babies and attempted murder of six babies, the focus of the nation is on the multiple tragedies that the families have faced, the healthcare staff who tried to blow the whistle, and safety issues in hospitals. NHS England has responded to the conviction by stating that trusts should look at whistleblowing policies, that those unfit to hold directorships should not be appointed, and with that well worn phrase “lessons will be learned.” But will they? In this BMJ opinion piece Alison Leary, professor of Healthcare and Workforce Modelling at London South Bank University, looks at why the NHS has failed to learn lessons from patient safety tragedies spanning the last fifty years. She highlights that unlike other safety critical industries, healthcare is still wedded to concepts that effectively deny the complexity of work and the social structures that surround work. This includes a failure to see the value in retaining experienced staff and a hierarchical approach to the value of work. She also outlines that more focus should be placed on management listening, rather than on staff having to find the courage to speak up when they have concerns: "When workers are listened to and constructive dissent is encouraged and normalised, along with the reporting of incidents, there is little need for whistleblowing. A workforce that must resort to whistleblowing is a symptom of poor safety culture."
  9. Content Article
    In 2011, the government acknowledged a large treatment gap for people with mental health conditions and sought to establish ‘parity of esteem’ between mental and physical health services. From 2016, the Department of Health & Social Care (DHSC) and NHS England made specific commitments to improve and expand NHS-funded mental health services. NHSE, working with the Department and other national health bodies, set up and led a national improvement programme to deliver these commitments. This report by the House of Commons Public Accounts Committee assesses progress made in delivering these commitments. The report acknowledges that NHS England has made progress in improving and expanding mental health services, but says this was "from a low base."
  10. Content Article
    In this interview for Times Radio, Sir Robert Francis KC, who led the 2010 inquiry into failures in care at Mid Staffordshire NHS Foundation Trust, discusses the benefits and disadvantages of statutory and non-statutory inquiries. In light of Lucy Letby's conviction for the murder of seven babies under her care while she worked as a NICU nurse, he also talks about how poor organisational culture can lead to staff covering up patient safety concerns.
  11. Content Article
    The aim of this study in the journal Pediatrics was to explore the impact of rudeness on the performance of medical teams. Twenty-four NICU teams participated in a training simulation involving a preterm infant whose condition acutely deteriorated due to necrotizing enterocolitis. Participants were informed that a foreign expert on team reflexivity in medicine would observe them. Teams were randomly assigned to either exposure to rudeness (in which the expert’s comments included mildly rude statements completely unrelated to the teams’ performance) or control (neutral comments). The videotaped simulation sessions were evaluated by three independent judges (blinded to team exposure) who used structured questionnaires to assess team performance, information-sharing and help-seeking. The authors concluded that rudeness had adverse consequences on the diagnostic and procedural performance of NICU team members. Information-sharing mediated the adverse effect of rudeness on diagnostic performance, and help-seeking mediated the effect of rudeness on procedural performance.
  12. Content Article
    This alert is for action by all those responsible for the use, purchase, prescription and maintenance of medical beds, trolleys, bed rails, bed grab handles and lateral turning devices including all Acute and Community healthcare organisations, care homes, equipment providers, Occupational Therapists and early intervention teams. From 1 January 2018 to 31 December 2022, the MHRA received 18 reports of deaths related to medical beds, bed rails, trolleys, bariatric beds, lateral turning devices and bed grab handles, and 54 reports of serious injuries. The majority of these were due to entrapment or falls. Investigations into incidents involving falls often found the likely cause to be worn or broken parts, which should have been replaced during regular maintenance and servicing, but which were either not carried out or were carried out improperly.
  13. Event
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    This webinar looks at a project by the Patients' Association and the Getting It Right First Time (GIRFT) programme that focuses on elective surgical hubs. These are surgical centres on existing hospital sites, separated from emergency services, which means the facilities can be kept free for patients waiting for planned operations, reducing the risk of short-notice cancellations. They can help reduce waiting times for some patients. They tend to specialise in uncomplicated surgical procedures, with particular emphasis on ophthalmology, general surgery, trauma and orthopaedics, gynaecology, ear nose and throat and urology. Speakers: Chloe Scruton, Senior Implementation Manager, GIRFT Hannah Verghese, Project Manager, the Patients Association Raj Patel, patient Shivani Shah, Head of Programmes (event chair) They will be joined by one of the patients who was part of the project. Register for the webinar
  14. Content Article
    This guide developed by Learn Together and Bradford Teaching Hospitals NHS Foundation Trust has been designed to help patients and families understand what to expect from patient safety investigations and how they can be involved in the process. It includes quotes and advice from patients who have been through patient safety investigations and spaces to record experiences, questions and reflections. The guide provides an outline of the investigation process, broken down into five stages: Understanding you and your needs Agreeing how you work together Giving and getting information Checking and finalising the report Next steps
  15. Content Article
    The UK is the “sick man” of Europe at the moment—on almost every health indicator including life expectancy, healthy life expectancy, obesity rates and healthcare capacity—we lag behind our peers. Recent data from the Office for National Statistics shows the substantial impact this is having on our national prosperity. The number of people who cannot work primarily because of long-term illness reached a record nearly 2.6 million. In this article for The Guardian, Professor Dame Sally Davies, former chief medical officer for England, argues that this is not the first time the UK has lagged behind on health outcomes and faced the associated economic harm. During the 19th-century Industrial Revolution and the 20th-century post-war period, Britain faced health crises that, like today’s, also undermined labour supply, economic participation and growth. She highlights that in both of these instances, national leaders implemented bold new public health strategies on both health and economic grounds and asks the question, 'Why is the Government not taking a more comprehensive policy approach to tackling the serious health issues we face in 2023?'
  16. News Article
    The leadership of a specialist trust in Liverpool is set to be taken over by the chief executive of the city’s main acute provider. A message to staff seen by HSJ said James Sumner, who leads Liverpool University Hospitals Foundation Trust, will also become interim CEO of Liverpool Women’s FT at the end of the year when Kathryn Thomson steps down. Ms Thomson announced her retirement in May. There have been long-standing ambitions to move Liverpool Women’s standalone hospital to the new Royal Liverpool Hospital site in the city centre, run by LUHFT, with a possible merger of the organisations. The relocation remains the ambition, although the trusts are focusing on service integration in the short term. The message to staff, sent this afternoon by chair Robert Clarke, said: “We have been clear for some time about our preferred future direction of travel for the trust, namely a closer collaboration with the large acute provider of services in the city as we believe this will support the long term clinical and financial sustainability of services for the benefit of women, babies and others who access our services. “Liverpool Women’s has secured agreement with NHS Cheshire & Merseyside on our ambition to move to a shared CEO model…This is a positive step in providing ongoing stability for Liverpool Women’s.” Read full story (paywalled) Source: HSJ, 30 August 2023
  17. Content Article
    The case of Lucy Letby, who was convicted of the murder of seven babies and attempted murder of another six in August 2023, has shocked both the public and the healthcare community. In this BMJ editorial, independent investigator Bill Kirkup and James Titcombe, Chief Executive of Patient Safety Watch, outline how the failure to listen to healthcare professionals raising concerns in the case may have contributed to further deaths. They highlight that when doctors at the Countess of Chester Hospital had concerns that they were seeing more deaths than expected, managers failed to take seriously their instinct that there might be a specific underlying cause. The doctors were even pressured into apologising to Letby. They argue that in spite of efforts by the NHS to create a culture where it is safe for staff to speak up about concerns, whistleblowers are still often ostracised and threatened when they highlight patient safety concerns. The article calls for health organisations to adopt the voluntary charter around candour currently being signed by police services and other bodies, pending the implementation of the proposed Public Authorities (Accountability) Bill, which would place a much-needed enduring duty of candour on NHS staff and organisations.
  18. Content Article
    Dr Chris Day has for the last ten years pursued a legal battle against Greenwich and Lewisham NHS Trust (GWT), claiming his whistleblowing action about unsafe staffing while working in ICU was used against him by the Trust and Health Education England. Following a 2022 employment tribunal involving Dr Day and GWT, consultancy firm KPMG was commissioned by the Trust to conduct an independent review of the Trust's governance and media strategy. In this LinkedIn blog, Dr Chris Day outlines the context of a Byline Times article that questions the independence of this review, due to director of corporate affairs at the Trust, Kate Anderson, being a former employee of KPMG.
  19. Content Article
    The number of cyberattacks and information system breaches in healthcare has grown steadily, escalating from isolated incidents to widespread targeted and malicious attacks. In 2022, 707 data breeches occurred in the US, exposing more than 51.9 million patient records, according to data from the Department of Health and Human Services (DHHS).  To help healthcare organisations address this growing patient safety concern, The Joint Commission has issued this Sentinel Event Alert that focuses on risks associated with cyberattacks and provides recommendations on how healthcare organizations can prepare to deliver safe patient care in the event of a cyberattack. 
  20. Content Article
    This toolkit provides information about how the US Department of Health and Human Services Office of the Director General conducted recent medical record reviews to identify patient harm. It outlines the decision criteria for adverse events and describes the methods used in the report, 'Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm' in October 2018, building upon a broader series of reports about adverse events in hospitals and other health care settings.
  21. News Article
    In the most deprived areas of England and Scotland, the nearest 24/7 accessible defibrillator is on average a round trip of 1.8 km away—over a mile—according to a pioneering study supported by the British Heart Foundation (BHF). The researchers, led by Dr Chris Wilkinson, senior lecturer in cardiology at Hull York Medical School, used data from national defibrillator network The Circuit to calculate the median road distance to a defibrillator with unrestricted public access across Great Britain's 1.7 million postcodes. Among the 78,425 defibrillator locations included, the median distance from the centre of a postcode to a 24/7 public access defibrillator was 726.1 metres – 0.45 miles. In England and Scotland, the more deprived an area was, the farther its average distance from a 24/7-accessible defibrillator – on average 99 metres more in England, and 317 metres farther in Scotland for people living in the most compared with the least deprived areas. There was no link between defibrillator location and deprivation in Wales. The researchers said they hoped the findings, presented at the European Society of Cardiology (ESC) Congress in Amsterdam and published in the journal Heart, would lead to more equal access to defibrillators. They noted that there were over 30,000 out-of-hospital cardiac arrests (OHCA) annually in the UK; in England nearly 30% happened at weekends, and 40% between 6pm and 6am. Read full story Read research study: Automated external defibrillator location and socioeconomic deprivation in Great Britain (28 August 2023) Source: Medscape, 29 August 2023
  22. Content Article
    The early use of automated external defibrillators (AEDs) improves outcomes in out-of-hospital cardiac arrest (OHCA). This study in the journal Heart investigated AED access across Great Britain according to socioeconomic deprivation. The authors found that in England and Scotland, there are differences in distances to the nearest 24/7 accessible AED between the most and least deprived communities. They concluded that equitable access to ‘out-of-hours’ accessible AEDs may improve outcomes for people with OHCA.
  23. Event
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    This year's World Patient Safety Day on 17 September will focus on engaging patients for patient safety, in recognition of the crucial role patients, families and caregivers play in the safety of healthcare. Ahead of World Patient Safety Day this webinar will provide an opportunity for those involved in patient safety to hear from patient safety leaders and discuss the opportunities and barriers to increasing patient engagement. It is co-hosted by the Patient Safety Commissioner for England and the charity Patient Safety Learning. The webinar will consist of a panel discussion and question and answer session with the following speakers: Dr Henrietta Hughes, Patient Safety Commissioner for England Jono Broad, Patient leader and a member of the South West Personalised Care Team Helen Hughes, Chief Executive of Patient Safety Learning Tracey Hanson, Patient Safety Partner at Central and North West London NHS Foundation Trust Sign up for the webinar
  24. News Article
    The NHS workforce plan will cost £50 billion and result in the health service employing half the public sector by the 2030s, analysis concludes today. Jeremy Hunt, the chancellor, has in effect “stolen more than a decade’s worth of budgets” from his successors by setting out plans to hire almost a million extra NHS staff without a clear way to pay for them, the Institute for Fiscal Studies (IFS) says. Hunt has been urged to use his autumn statement to start setting out whether tax rises, borrowing or cuts elsewhere will be used to fund the “massive spending commitment”. Read full story (paywalled) Source: The Times, 30 August 2023
  25. News Article
    Targeted screening of patients with type 2 diabetes could more than double new diagnoses of heart conditions, a study suggests. When applied at a larger scale, such an approach could translate into tens of thousands of new diagnoses, researchers believe. Conditions such as coronary artery disease, atrial fibrillation and heart failure affect millions of people worldwide, causing a large number of deaths and increasing healthcare costs. Treatments are available that can prevent stroke or acute heart failure, but systematic screening is not currently common practice. Those living with conditions such as type 2 diabetes or chronic obstructive pulmonary disease (COPD) – a group of lung conditions that cause breathing difficulties – are at high risk of such conditions. A team of researchers led by Dr Amy Groenewegen, from the University Medical Centre Utrecht in the Netherlands, has developed a three-step screening process to detect conditions in high-risk people at an early stage. Study author Dr Groenewegen said: “An easy-to-implement strategy more than doubled the number of new diagnoses of heart failure, atrial fibrillation and coronary artery disease in high-risk patients.” Read full story Source: Independent, 29 August 2023
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