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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Event
    This webinar for UK healthcare professionals will be delivered by DISN UK Group committee members. It will focus on using diabetes technology–insulin pumps, CGM, POCT–in the hospital. We will discuss and outline the newest JBDS technology guideline and provide the attendees with most up to date information regarding using diabetes technology when a person with diabetes is admitted to hospital. Educational outcomes – 3 points: Recognise different types of diabetes technology Use of diabetes technology in the different scenarios in inpatient setting Effective support for people with diabetes and use of diabetes technology when admitted to hospital Register for the webinar
  2. News Article
    The proportion of NHS staff who have experienced physical violence from patients has fallen to its lowest levels in five years, according to the latest survey data. New figures showed the percentage of staff reporting at least one incident of physical violence from patients or the public, within the last 12 months, had declined from 15.1 per cent in 2019, down to 13.7 per cent in 2023. That is also almost one percentage point lower than 14.6 per cent in 2022, which is the biggest year-on-year percentage point fall in the five years. The 2023 NHS staff survey, first published in early March, was updated recently to include the questions on physical violence. NHS England said earlier this week it had received a “higher than expected rate of missing data” for the questions, which meant they were not originally reported, but these issues had now been resolved. However, ambulance workers remain disproportionately affected by physical violence compared to other roles, with 27.6 per cent saying they had experienced at least one instance of physical violence from patients or the public in the past year. This is down from 32.5 per cent five years ago in 2019. Acute and community staff were the next highest (13.7 per cent), followed by mental health (13.5 per cent), community (7 per cent), and then acute specialist (5.3 per cent). Read full story (paywalled) Source: HSJ, 5 June 2024
  3. Content Article
    The maternity disadvantage assessment tool (MatDAT) is a standardised tool for assessing social complexity during maternity care based on women and birthing people’s broad social needs. Developed by the Royal College of Midwives (RCM), it provides a guide for midwives to identify the woman’s care level (Level 1–4) and develop a personalised care and support plan (PCSP), as well as facilitating smooth communication with the multidisciplinary team. The tool and the MatDAT Planning Guide also support maternity services to plan and allocate resources to level of care pathways.
  4. News Article
    A national study is examining whether a treatment for premature babies could cause harm, amid concerns about the deaths of four infants last year, it has emerged. HSJ has learned a national study into the use of prophylactic low-dose hydrocortisone steroids, also known as “premiloc”, is being carried out at the Neonatal Data Analysis Unit, part of the Imperial College London Medical School. Meanwhile, University College London Hospitals Foundation Trust confirmed that four children died in January and February 2023 last year, having been transferred from UCLH to nearby Great Ormond Street Hospital, after receiving the treatment. They had been given hydrocortisone steroids at UCLH to reduce the risk of developing a lung condition called bronchopulmonary dysplasia. UCLH said its own internal investigations “did not confirm a direct link” between the deaths and the drug, “but concern remained” so they were reported to the regional neonatal network. UCLH noted that the national study at Imperial was now under way, although the Imperial team told HSJ it was not specifically aware of the UCLH/GOSH deaths last year. A report from GOSH’s safety team last year, seen by HSJ, said: “In all four deaths the mortality review group identified modifiable/potential modifiable factors around the administration of premiloc prior to admission to GOSH. Administration of premiloc (hydrocortisone steroids) to these babies may have been associated with the subsequent perforations. A series of incidents of perforations was flagged to the UCLH neonatal unit who reviewed data and have stopped the administration of premiloc.” Read full story (paywalled) Source: HSJ, 5 June 2024
  5. Content Article
    This study in BMC Infectious Diseases aimed to estimate the contribution of individual interventions (together and in combination) to the effectiveness of the overall package of interventions implemented in English hospitals during the Covid-19 pandemic. The study simulated scenarios to explore how many nosocomial infections might have been seen in patients and healthcare workers if interventions had not been implemented. We simulated the time period from March 2020 to July 2022 encompassing different strains and multiple doses of vaccination.
  6. Content Article
    Sofia Mettler, MD, describes the day when the electronic medical records (EMR) system at her hospital failed and the impact this had on clinical decision making. She highlights that the downtime forced doctors across the hospital to speak with patients about their condition and symptoms, and to collaborate with the nurses who had been monitoring them all night. It also made her realise that the many test results she was used to referencing for every patient were not all necessary to make clinical decisions. She reflects, "The EMR downtime made me realise that while the system seems to make our clinical routine convenient, it may not result in increased efficiency or better patient care."
  7. Content Article
    This multihospital prospective study in Surgery aimed to determine whether strict adherence to an enhanced recovery after surgery protocol leads to improvement in outcomes, compared with less strict compliance. The study looked at all consecutive anatomic lung resection patients on the thoracic enhanced recovery after surgery pathway from May 2021 to March 2023 and compared this cohort with a historical control from January 2019 to April 2021. The authors found that enhanced recovery after surgery protocols improve outcomes after anatomic lung resection, and that increasing compliance to individual elements further improves patient outcomes. They argue that continued efforts should be directed at increasing compliance to individual protocol elements.
  8. News Article
    More hospital patients with learning disabilities will die if politicians do not tackle the “devastating collapse” in specialist nurse numbers, a leading charity and a union have warned. The number of specialist learning disability nurses working in the NHS has dropped by 44 per cent over the course of the Conservative party’s time in government, a new analysis by the Royal College of Nursing (RCN) has revealed. The nursing union found a 36 per cent drop in applicants for specialist nursing degrees, while applicants are so low some universities have stopped funding courses altogether, according to a report shared exclusively with The Independent. The RCN and the charity Mencap have warned specialist nurses are vital in keeping patients with learning disabilities in hospital safe, as they are trained to spot life-threatening illnesses, such as sepsis, which can present differently. Dan Scorer, head of policy at Mencap, said: “Learning disability nurses have that in-depth training and understanding about the complexity of how people with a learning disability can present, and about how they will show they are experiencing pain. They’ve got vital expertise and insights to make sure that we don’t miss things.” He said the government must increase the number of training places available, and warned some universities have stopped courses altogether. He added: “I think the government removing bursaries for nurse training was pretty devastating. The impact of that was really significant, and whilst that’s been partially reversed, it significantly impacted the undergraduate training capacity that was available.” Read full story Source: The Independent, 4 June 2024
  9. Content Article
    Over 65% of all new drugs undergo expedited drug approval in the USA, and these drugs have been linked to a higher prevalence of adverse drug reactions, raising concerns about safety. It is well documented that women generally report a higher frequency of adverse drug reactions than men, but whether women have more adverse drug reactions than men from drugs approved via expedited pathways is unknown. This brief Lancet article outlines the findings of a systematic review that assessed sex differences in data reporting and highlighted a knowledge gap as to whether women face a higher risk of harm through expedited approval pathways than men.
  10. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Making Families Count is an organisation that offers practical training based on lived experience to healthcare professionals.  Rosi talks to us about how MFC training benefits patient safety and improves the way in which patients and families are involved in incident investigations. She explains how she came to be involved in MFC after the death of her son Nico and outlines the vital importance of seeing patient and family voices as equal to those of people working for healthcare organisations.
  11. Content Article
    Despite not being indicated for lactation in the UK, the anti-sickness medicine domperidone is increasingly being prescribed or bought illegally to aid lactation, but its side-effects can include anxiety, depression and suicidal thoughts. In this account for The Guardian, Rose Stokes describes her experience of being prescribed domperidone after the birth of her son. When her milk production didn't increase and with her mental health rapidly deteriorating, Rose bought her own supply of the drug online and through a private doctor and ended up taking more than five times the NHS maximum dose. When her mental state continued to worsen, she decided to suddenly stop taking domperidone which left her suicidal. She describes receiving no guidance on the mental health risks associated with the medication or sudden withdrawal.
  12. 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.
  13. 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
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. 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.
  20. 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. 
  21. 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.
  22. 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.
  23. 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.
  24. 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.
  25. 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.
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