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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. News Article
    The use of surgical mesh to treat a common childbirth injury is now suspended in New Zealand because of safety concerns. The extraordinary step, which follows a similar move in the United Kingdom, was announced today by Te Whatu Ora. It is being celebrated by a woman who spearheaded a campaign to highlight the harrowing mesh injuries suffered by her and many other Kiwi women. “It is an acknowledgement that their concerns were not just in their heads,” Sally Walker told the Herald. “It will give us some hope.” About 100 women around the country who are on waiting lists for urogynaecological surgeries involving mesh are being contacted by doctors to tell them their operations for stress urinary incontinence are on hold. The Director-General of Health Dr Diana Sarfati said the Surgical Mesh Roundtable (MRT), an oversight and monitoring group chaired by the Ministry of Health, had been investigating a “pause” since earlier this year. The group’s assessment was that the balance of benefit and harm from the procedure would be improved by the series of additional measures already planned, and it recommended a pause until those measures were substantively in place. “After considering the MRT’s assessment, I have decided to support a pause to allow the following steps to be put in place to reduce the harms linked to the procedure as much as possible,” said Sarfati. Read full story Source: NZ Herald, 22 August 2023
  2. Content Article
    Publicly available data from the Office for Health Improvement and Disparities (OHID) shows a persistently high number of excess deaths involving cardiovascular disease (CVD) in England since the beginning of the pandemic. This analysis of by the British Heart Foundation looks at this situation in more detail.
  3. Content Article
    This is the report of a review into how the executive leadership of the NHS could be better supported and empowered to ensure the best possible service is delivered for patients. Sir Ron Kerr was commissioned by the Department of Health and Social Care (DHSC) to conduct the review, which focused on three issues in particular: The expectations and support available for leaders - particularly those in challenging organisations and systems The scope for further alignment of performance management expectations at the organisational and system level The options for reducing the administrative burden placed on executive leaders The report describes the methodology of the review, outlines its findings and makes a number of recommendations around these issues.
  4. Content Article
    The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 aimed to: minimise burdens on public, independent and third sector employers and ensure businesses in UK are not placed at competitive disadvantage relative to EU counterparts offer good standards of protection to healthcare workers from risk of sharps injury at work see a fall in sharps injury numbers. This post implementation review (PIR) aimed to assess the success of these objectives. It found that: stakeholder consultation provided evidence of the increasing use of safer sharps across all healthcare sectors. evidence from RCN research and HSE inspections indicates that risks to healthcare workers from sharps injuries remains high. The policy conclusion from this evidence is that the Regulations are still required, and that the Regulations’ objectives cannot be met with a system that imposes less burden to business.
  5. Content Article
    The Prescribing Safety Assessment (PSA) is a 60-question exam required as part of UK medical training to progress from FY1 to FY2. This independent review into the PSA was commissioned by the Medical Schools Council (MSC) together with the British Pharmacological Society (BPS) in the summer of 2022. It suggests a strategic future direction for the PSA and addresses how the PSA has impacted prescribing assessment and practice for medical students and Foundation Year 1 (FY1) doctors. It is intended to support national decision making about the future of UK prescribing assessment in the context of the imminent introduction of the Medical Licensing Assessment (MLA).
  6. Content Article
    Calibration, defined as alignment between a person’s diagnostic accuracy and their confidence in that accuracy, is an essential component of diagnostic excellence. Miscalibration—the misalignment between a person’s diagnostic accuracy and their confidence in that accuracy—can manifest as either overconfidence or underconfidence and can have serious consequences for patient diagnosis. This resource about calibration from the US Agency for Healthcare Research and Quality (AHRQ) is primarily aimed at individual clinicians whose scope of practice includes diagnosis. It focuses on processes involved in making a diagnosis and the outcome of giving an explanatory label to patients after these processes unfold.
  7. Content Article
    This study in the Journal of Medical Virology aimed to assess the extent and the disparity in excess acute myocardial infarction (AMI)-associated mortality during the pandemic, focusing on the outbreak of the Omicron strain. Using data from the US Centers for Disease Control and Prevention's (CDC's) National Vital Statistics System, the authors found that excess death, defined as the difference between the observed and the predicted mortality rates, was most pronounced for the 25–44 years age group. Excess deaths ranged from 23%–34% for the youngest compared to 13%–18% for the oldest age groups. The trend of mortality suggests that age and sex disparities have persisted even through the Omicron surge, with excess AMI-associated mortality being most pronounced in younger-aged adults.
  8. Content Article
    The UK spends significantly less on capital, such as buildings and equipment, than most other Organisation for Economic Co-operation and Development (OECD) countries. This may contribute to its poor performance on outcomes compared with similar countries.  This Health Foundation report analyses trends in the capital budget, comparing the UK with international averages. Using annual data from all NHS trusts in England. It then focuses on trends in the capital spending of NHS trusts to analyse where money has been spent and where there are areas of need. It then analyses the implications of recent capital spending, with a specific focus on NHS trusts’ maintenance backlog. The report concludes with a discussion of the trends in capital spending and capital levels, and implications and recommendations for future health care funding.
  9. Content Article
    .As healthcare organisations continually strive to improve, there is a growing recognition of the importance of establishing a culture of safety. This handbook was published by Healthcare Improvement Scotland to support NHS board maternity services to: understand the importance of safety culture. undertake a patient safety climate survey. understand what the survey results are telling them. develop an improvement plan to address areas that have been highlighted. It includes: the Maternity Services Patient Safety Survey. template letters for NHS boards to adapt for local use. an example improvement plan template.
  10. Content Article
    Despite the prevalence of diabetes amongst individuals with Serious Mental Illness (SMI), diabetes care is not currently audited within mental health inpatient settings as it audited in physical health settings. This project piloted an audit to assess the diabetes care within London NHS Mental Health Trusts. The Health Innovation Network in partnership with South London and Maudsley NHS Foundation Trust (SLaM) developed and piloted a diabetes audit. Following the SLaM pilot, the audit was completed by all nine London Mental Health Trusts. A diverse approach was taken to spread and adoption. This included piloting the audit within one MH Trust, refining, and then rolling out the audit to eight London Mental Health Trusts.
  11. Content Article
    For Every Pregnancy is a campaign by the Nursing & Midwifery Council. It aims to show that each pregnancy is unique, and whatever stage you're at, your midwife team should be right alongside you. The campaign includes posters and videos aimed at outlining the standards of care pregnant women and birthing people can expect and the importance of shared decision making.
  12. Content Article
    This briefing was commissioned by the Maternal Mental Health Alliance who are dedicated to ensuring all women, babies and their families across the UK have access to compassionate care and high-quality support for their mental health during pregnancy and after birth. One woman in five experiences a mental health problem during pregnancy or after they have given birth. Maternal mental health problems can have a devastating impact on the women affected and their families. NICE guidance states that perinatal mental health problems always require a speedy and effective response, including rapid access to psychological therapies when they are needed. Integrated care systems (ICSs) have a unique opportunity to ensure that all women who need support for their mental health during the perinatal period get the right level of help at the right time, close to home.
  13. Content Article
    There is a well-established case for involving communities and people with lived experience in health and care policy, service design and delivery. NHS England guidance on working in partnership with communities highlights the financial benefits and improvements to quality and health outcomes that working with local communities brings. But could this involvement go further? In this article, Loreen Chikwira, Researcher at The King's Fund looks at the arguments for the use of intersectional approaches in understanding people’s lived experience of care in tackling ethnic health inequalities. These intersectional approaches help health and care providers shift their focus from people’s behaviours to also identifying and addressing ways of working that create and reinforce inequalities and poor experiences of care.
  14. Content Article
    The UK Government is seeking the views of members of the public on an interim delivery plan to improve experiences and outcomes of people with myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS). The consultation asks for views on: research attitudes and education living with ME/CFS language used in relation to ME/CFS The responses will be used to help the Government understand:how well the plan identifies and addresses the issues most important to the ME/CFS community and where further action may be required. This consultation closes at 11:59pm on 4 October 2023.
  15. Event
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    At this event, Christiana Melam will be talking about all things to do with social prescribing. Christiana is the Chief Executive of the National Association of Link Workers, the UK's professional network for social prescribing link workers. She is an advocate for diversity, inclusion, coproduction, bottom-up approaches, social justice, empowering people and reducing inequality. In conversation with our Chief Executive, Rachel Power, Christiana will explore the value of social prescribing, a model of care that connects people to activities, groups, and services in their community to meet the practical, social and emotional needs that affect their health and wellbeing. Sign up for this free Zoom webinar.
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    The Patient's Association is delighted to welcome back Dr Henrietta Hughes, Patient Safety Commissioner, to Patient Partnership Week. Her conversation with Chief Executive Rachel Power during last year's Patient Partnership Week was one of the week's most popular events. If you missed last year's webinar, then the event on Monday 25th September at 2.30pm is your chance to hear from Dr Hughes about her first year as Patient Safety Commissioner for England. It's free to sign up to the webinar, which will be held on Zoom.
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    Sara Turle is a Patient and Public Voice Partner with NHS England and a member of Kent & Medway Cancer Alliance. She is passionate about partnership working with the NHS. On Tuesday 26th September at 12pm, she'll be talking about her journey in patient partnership, why partnership is important, and advice she would give to patients and professionals with our Chief Executive Rachel. To listen in on what will be a fascinating discussion about patient partnership book your place on this free webinar.
  18. Event
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    Professor Bola Owolabi, Director of the National Healthcare Inequalities Improvement Programme at NHS England, will be kicking off Patient Partnership Week 2023 on Monday 25th September. Prof Owolabi, who also works as GP in the Midlands, will be in conversation with Rachel Power, Chief Executive of the Patients Association. They'll be talking about the vital role partnerships with patients and communities play in tackling health inequalities. Sign up for this free event which will be held on Zoom About CORE20PLUS5 Prof Owolabi has spearheaded NHS England’s Core20PLUS5 approach to narrowing healthcare inequalities. Core20PLUS5 is a national approach to reducing healthcare inequalities. It defines a target population – the ‘Core20PLUS’ – and identifies ‘5’ clinical areas that require improvement. The Core20 refers to the most deprived 20% of the population. The PLUS are groups identified in a local area such as ethnic minority communities or people with multiple long-term health conditions. The 5 are these clinical areas: maternity, severe mental illness, chronic respiratory disease, early cancer diagnosis, and hypertension.
  19. News Article
    NHS England could have gone further to insist that errors and failures by senior NHS leaders are disclosed to future employers, according to the leading barrister who reviewed the NHS’s fit and proper person test (FPPT). Tom Kark KC’s review of the FPPT was delivered to government five years ago and made public the following year, and changes were finally proposed by NHSE earlier this month. In an interview with HSJ, Mr Kark said he broadly welcomed the plans, and that the revised framework should provide greater consistency across NHS boards “if applied correctly”; and could “strengthen the hand” of chairs and chief executives. Part of the purpose of the regime is to prevent senior managers and other board members who make big errors in one role, from keeping this secret from a future employer. Mr Kark told HSJ he had heard evidence that when “someone leaves under a cloud, they pop up somewhere else, and the information is lost.” Read full story (paywalled) Source: HSJ, 16 August 2023
  20. Content Article
    At the beginning of 2023, The Jordan Legacy launched a new strategy designed to raise the bar in terms of collective ambition in suicide prevention and to plot a course of collective practical action that can realise that ambition. This report is the first in a series summarising what is emerging from this action research project, as well as the organisation's wider, ongoing action learning initiatives, focusing on reducing the number of suicides in the UK. The researchers asked people affected by suicide to provide responses to two key questions: How can we significantly reduce the annual number of suicides in the UK, from the 6000+ level it’s been at for 15 years? How far can we go?
  21. News Article
    The Government must provide the health service with more support to fulfil its ambition of extending healthy life expectancy and reducing premature death, an expert has warned. It comes after the Department for Health and Social Care (DHSC) published an interim report on its Major Conditions Strategy, a 5-year blueprint to help manage six disease groups more effectively and tackle health inequality. The groups are cancer, cardiovascular disease – including stroke and diabetes – musculoskeletal conditions, chronic respiratory diseases, mental health conditions and dementia. The Government said the illnesses "account for over 60% of ill health and early death in England", while patients with two or more conditions account for about 50% of hospital admissions, outpatient visits, and primary care consultations. By 2035, two-thirds of adults over 65 are expected to be living with two or more conditions, while 17% could have four or more. Sally Gainsbury, Nuffield Trust senior policy analyst, said the Government is right to focus on the six conditions, but "will need to shift more of its focus towards primary prevention, early diagnosis, and symptom management". She added: "What's less clear is how Government will support health and care systems to do this in the context of severe pressures on staff and other resources, as well as a political culture that tends to place far more focus on what happens inside hospitals than what happens in community healthcare services, GP practices and pharmacies. This initiative is both long overdue and its emphasis has shifted over time. The Major Conditions Strategy is being developed in place of a White Paper on health inequalities originally promised over 18 months ago." Read full story Source: Medscape, 16 August 2023
  22. Content Article
    This guide published by NHS England & Improvement describes the validation rules relating to the LFPSE project, specifically around submitting an Adverse Event via the Adverse Event Application Programming Interface (API). It covers several types of validation rules, which have been split into three sections. Bespoke business validation rules which have been implemented based on the dependencies between responses and extensions that cannot be captured by the FHIR resource validation. FHIR validation responses which may be returned from the API when native FHIR validation checks the submission body against the LFPSE FHIR profiles defined for an adverse event. Invalid operations and similar responses which are external to validation of the submission, including responses pertaining to permissions, personal information and any other responses that do not fit into the two categories above.
  23. Event
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    This popular training day covers the must do’s and the grey areas around the statutory Duty of Candour, with a strong emphasis on going beyond mere compliance and delivering the duty of candour in a meaningful way for patients and families and for the staff involved and the organisation. It has been updated to directly support the successful implementation of the PSIRF guidance and the ‘Harmed Patient Pathway’. The training is delivered by Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. Prices £245 (plus vat) per person Discounted rate for bookings of 3 or more: £220 (plus vat) per person Book a place Watch introductory video about the course
  24. News Article
    Roughly three in 10 adults have been addicted to opioids or have a family member who has been, and less than half of those with a substance use disorder have received treatment, according to a new survey conducted by KFF, a health policy research group. The survey, which polled more than 1,300 adults in July, underscores the broad and often harmful influence of opioid addiction across the nation, which recorded around 110,000 fatal drug overdoses last year alone. And the findings suggest that some proven medications for helping curb drug cravings, such as buprenorphine and methadone, are still not getting to those who need them. Only 25 percent of participants in the poll who said they or someone in their family had an opioid addiction reported receiving medication for themselves or family members. Mollyann Brodie, the executive director of KFF’s polling program, said that the numbers might be an undercount, as some survey participants might have been hesitant to share histories of opioid addiction. Addiction cuts across class, race and geography, the KFF researchers found. Rural and white Americans were the likeliest to report personal or family opioid addiction, but significant percentages of Black, Hispanic, urban and suburban families did, as well. White families were more likely than Black or Hispanic families to say that they had received treatment. Overdose fatality rates among Black Americans have climbed substantially in recent years, the Centers for Disease Control and Prevention found in a study last year. Dr. David Fiellin, an addiction physician at the Yale School of Medicine, said the survey showed the need for a stronger federal response to substance use disorders, akin to the one for AIDS. He said, “There’s often a misunderstanding of what treatment actually looks like and what it is—people often look to a quick fix,” he said, referring to a detox strategy. “Effective treatment tends to be much more long term and requires addressing the denial that can be part of the condition.” Read full story (paywalled) Source: New York Times, 15 August 2023
  25. News Article
    Young people who vape are more at risk of bronchitis and shortness of breath, research has suggested, even if they also smoke cigarettes. Researchers from the US tracked the respiratory health of young people in the Southern California Children’s Health Study between 2014 and 2018. They conducted surveys which asked about people’s vape and cigarette use in the last 30 days. Researchers also included questions on bronchitic symptoms, such as a daily cough for three months in a row, as well as wheezing and shortness of breath. The study found the odds of wheezing were 81 per cent more likely among past 30-day e-cigarette users than among “never users”. The odds of bronchitic symptoms were twice as likely, while those of shortness of breath were 78 per cent more likely after accounting for survey wave, age, sex, race and parental education. The researchers said their findings contribute to “emerging evidence from human and toxicological studies that e-cigarettes cause respiratory symptoms that warrant consideration in regulation of e-cigarettes.” Jon Foster, policy manager at Asthma + Lung UK, said it is “interesting” the study found a link between vaping and lung conditions in young people, but pointed out the regulation around the amount of nicotine and chemicals used in e-cigarettes is “much tighter” in the UK than the US. “More research would be needed to find out if the situation in the UK is the same,” he added. “However, given that we still know little about long-term effects, the growing popularity of vaping among children and young people is concerning.” Read full story Source: Independent, 16 August 2023
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