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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    In this article, critical criminologist Sharon Hartles looks at the ongoing fight for justice by families affected by the hormone pregnancy test (HPT) Primodos. Primodos was given to thousands of women in the 1960s and 70s which has been linked to miscarriages, birth defects and stillbirth. The Department of Health and Social Care (DHSC) and pharmaceutical company Bayer are applying to strike out court proceedings against them in a civil litigation case brought by the Association for Children Damaged by Hormone Pregnancy Tests (ACDHPT). This would prevent a five-day hearing scheduled to take place at the Royal Courts of Justice in May 2023 from going ahead. The article outlines the argument brought by the DHSC and Bayer that no additional evidence has been found to warrant the case being brought by the ACDHPT. It then goes on to highlight recent research that has established a causal link between HPTs and birth malformations and that therefore gives credence to the litigation. Sharon highlights the importance of the legal system acknowledging and confronting the damage inflicted upon the families affected by the use of Primodos, many of whom have been seeking justice for decades. Related reading Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response (Sharon Hartles, August 2021) Sodium Valproate: The Fetal Valproate Syndrome Tragedy A year on from the Cumberlege Review: Initial reflections on the Government’s response (Patient Safety Learning, 23 July 2021)
  2. News Article
    Just three years of breathing polluted air can increase a person’s risk of lung cancer, a study has found. Scientists have found, for the first time, the mechanism that proves air pollution causes lung cancer to develop. Research funded by Cancer Research UK and conducted by the Francis Crick Institute showed that small pieces of carbon particulates, known as PM2.5, enter deep into the lungs and lead to tumour development. A key gene, known as EGFR, mutates and then the presence of the air pollution exacerbates the growth and expansion of these mutated cells, the study found. The scientists are hopeful that by shedding light on how lung cancer develops they can help to prevent it. Prof Charles Swanton, the chief clinician for Cancer Research UK and lead investigator on the study, said a statin-like drug to protect against lung cancer and ensure the inflammation that can lead to the disease is kept under control could be developed in as little as 10 years. Prof Swanton said: “Our study has fundamentally changed how we view lung cancer in people who have never smoked." Read full story (paywalled) Source: The Telegraph, 5 April 2023
  3. News Article
    Lives could be saved by a new tool that identifies those most at risk of developing lung cancer, according to researchers. The CanPredict tool can spot those most at risk of developing the disease over the next decade and put them forward for screening tests earlier, researchers from the University of Oxford and the University of Nottingham said. They created and tested CanPredict using the anonymised health records of more than 19 million adults from across the UK and hope it can save “time, money and, most importantly, lives”. Lung cancer is the leading cause of cancer deaths worldwide and the second most common form of the disease, but early diagnosis has been shown to improve survival rates. Professor Julia Hippisley-Cox, senior author and professor of clinical epidemiology and general practice at the Nuffield Department of Primary Care Health Sciences, University of Oxford, said: “We hope that this new validated risk tool will help better prioritise patients for screening and ultimately help spot lung cancer earlier when treatments are more likely to help. We’d like to thank the many thousands of GPs who have shared anonymised data for research without whom this would not have been possible.” Read full story Source: The Independent, 6 April 2023
  4. News Article
    An independent group overseeing the reviews into a toxic culture at University Hospitals Birmingham have raised concerns over a possible ‘cover up’ of key reports. The cross-party reference group, which includes MPs, council and Healthwatch officials, has demanded transparency over key decisions, and says there are continuing concerns over the trust’s leadership. It has been scrutinising a review into patient safety concerns at UHB, which found the trust’s executive had become “overzealous and coercive”. On the day this review was released, it was revealed that UHB’s former CEO David Rosser had decided to retire. The group, chaired by MP Preet Gill, said in a statement: “The allegations made by whistleblowers were not isolated incidents, but the result of a deep-seated and toxic culture. While Dr Rosser has recently announced his retirement, one member of staff, albeit a chief executive, cannot be responsible for this alone. Feedback from staff has made it clear that there must be collective accountability by the senior leadership for the distressing culture afflicting the trust." Read full story (paywalled) Source: HSJ, 5 April 2023
  5. News Article
    Some of the most vulnerable patients could risk missing out on covid treatment because new rules will place the onus on them to access antiviral medication themselves instead of the NHS contacting them directly, senior figures have warned. The warnings follow NHS England’s national medical director Sir Stephen Powis writing to local leaders last week advising them the national commissioner will no longer identify patients who are eligible for covid treatment. This means eligible patients will need to contact local services themselves, rather than being approached proactively by a covid medicines delivery unit. Patients Association chief executive Rachel Power said: “Expecting patients ill with covid to know they’re eligible for these treatments and ask for them is unreasonable. How will they know they’re eligible or who to contact?” Read full story (paywalled) Source: HSJ, 6 April 2023
  6. Content Article
    The Healthcare Safety Investigation Branch (HSIB) will transition into new arms-length body The Healthcare Services Safety Investigation Body (HSSIB) in October 2023. In this article, HSSIB's Chair Designate, Ted Baker, reflects on: how the Francis Inquiry was instrumental in changing the view of patient safety in the NHS. the role of HSIB over the last five years in identifying systemic causes of patient harm. what the future holds for HSSIB.
  7. Content Article
    This report outlines the results of the Patient Information Forum's (PIF's) 2022 survey and sets out progress made in the crucial areas of health and digital literacy since the Covid-19 pandemic.
  8. Content Article
    The overall goal for the Quality and Safety Education for Nurses (QSEN) project is to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes necessary to continuously improve the quality and safety of the healthcare systems they work in. This webpage outlines the competencies in the QSEN competency framework: Patient-Centered Care Teamwork and Collaboration Evidence-based Practice (EBP) Quality Improvement (QI) Safety Informatics
  9. News Article
    The parents and children of victims of the contaminated blood scandal should receive government compensation, a judge has said. The chairman of the infected blood public inquiry, Sir Brian Langstaff, said it was time to "recognise deaths which have so far gone unrecognised". More than 3,000 people died after contracting HIV or hepatitis C via NHS treatments in the 1970s and 80s. The government must now respond to the recommendations. In August 2022, the government agreed to make the first interim compensation payments of £100,000 each to about 4,000 surviving victims, and bereaved widows. Sir Brian said, "It is a fact that around 380 children with bleeding disorders were infected with HIV. Some of them died in childhood. But their parents have never received compensation. Children who were orphaned as a result of infections transmitted by blood transfusions and blood products have never had their losses recognised. It's time to put that right." Read full story Source: BBC News
  10. News Article
    Delays in people leaving hospital in England could be costing an average of £395 per night, according to researchers at a health think tank. The direct costs of delayed discharges, where patients are considered medically fit to leave hospital, is estimated to be around £1.89 billion for the past financial year, the King's Fund said. This estimate does not count extra costs, including cancelled operations or staff time spent arranging care packages. Ambulance handover delays are often linked to a shortage of space caused by people who no longer need to be in hospital beds. The most recent PA analysis of NHS figures showed an average of 13,300 beds per day in the week to March 26 were filled by people ready to be discharged, compared with 12,643 at that point last year. Overall, 42% of medically fit patients in England were discharged, though the rate varied between regions, from 31% in the North West to 52% in eastern England. Read full story Source: Medscape, April 2023
  11. News Article
    A virus carried by ticks, which is common in many parts of the world, is now present in the UK and health officials are reminding the public how to avoid bites from the tiny bugs. They say the risk of tick-borne encephalitis is very low—only one person is confirmed to have been infected in England so far, last year. But the tick species which carries the virus is widespread in the UK. Most people do not develop symptoms but swelling to the brain is possible. The UK Health Security Agency has recommended changes to testing in hospital so that any new cases can be picked up quickly. Health officials say anyone who becomes unwell after a tick bite should see a GP. More serious symptoms to look out for include severe headache, stiff neck, unexplained seizure, sudden confusion and weakness in arms and legs. Read full story Source: BBC News, 5 April 2023
  12. News Article
    A new non-invasive diagnostic test for oral cancer test developed by researchers at the University of Surrey is said to be over 92% accurate at detecting oral squamous cell carcinoma (OSCC) and more than 80% accurate at identifying pre-cancerous oral epithelial dysplasia (OED), according to a proof-of-concept study. The news comes in the wake of a recent report showing that cases of oral cancer in the UK increased by 34% over the last decade and have more than doubled compared with 20 years ago. The State of mouth cancer UK report 2022, released last November by the Oral Health Foundation, showed that there were 8846 new cases of mouth cancer diagnosed in the UK over the previous year, with 3034 deaths from the disease. The test could pave the way for better oral cancer detection, the researchers said. The samples were collected in dental surgeries and mailed to their laboratory for analysis, which demonstrated that the test could be "used in primary care to identify patients in need of specialist care". Study co-author Dr Fatima Labeed, senior lecturer in human biology from the University of Surrey, said: "Over 300,000 people are diagnosed with oral cancer worldwide–a disease with an alarming mortality rate of around 50%. This suggests that the scientific community doesn't have the tools available to identify oral cancer early enough, and we hope that PANDORA paves the way for more effective clinical diagnostic tools for this terrible disease." Read full story Source: Medscape, 5 April 2023
  13. Content Article
    This report by Press Ganey outlines the key trends shaping safety culture in 2023 and makes recommendations for senior healthcare leaders to create and sustain safety culture across their organisations. Based on survey data from 814,000 US healthcare professionals, it highlights that in 2022 there was an upward trend in the perception of safety culture among clinical and nonclinical staff, but perception continues to trend downwards among senior leadership and doctors.
  14. Content Article
    In this article, published in the Future Healthcare Journal, Helen Hughes, Chief Executive of Patient Safety Learning, reflects on how avoidable harm continues to occur, ten years on from the Francis report into major patient safety failings at Mid Staffordshire NHS Foundation Trust. She describes an implementation gap—where safety concerns and issues highlighted in inquiries and reviews are not being translated into improvements in patient safety. The article outlines some of the key barriers to implementation and suggests what needs to change to ensure we truly learn lessons from patient safety scandals such as Mid Staffordshire.
  15. News Article
    Critically ill patients “will inevitably die” because hospitals are having to cancel surgery as a direct result of next week’s junior doctors’ strike in England, leading heart experts have warned. There were bound to be fatalities among people with serious heart problems whose precarious health meant they were “a ticking timebomb” and needed surgery as soon as possible, they said. They added that patients would face an even greater risk than usual of being harmed or dying if their time-sensitive operation was delayed because NHS heart units would have too few medics available during the four-day stoppage by junior doctors to run normal operating lists. The trio of cardiac experts are senior doctors at the Royal Brompton and Harefield specialist heart and lung hospitals in London. Those facilities, plus the cardiac unit at St Thomas’ hospital in the capital, have between them postponed between 30 and 40 operations they were due to conduct next week on “P2” patients, whose fragile health means they need surgery within 28 days. “It is no exaggeration to say that delaying surgery for this group [P2s] will result in harm. For some, this may be life-changing. For others, it may mean premature death,” said Dr Richard Grocott-Mason, a cardiologist who is also the chief executive of the Royal Brompton and Harefield hospitals. Read full story Source: The Guardian, 4 April 2023
  16. News Article
    Two concurrent outbreaks of the Marburg virus, a close cousin of Ebola that can kill as many as 90 percent of the people it infects, are raising critical questions about the behaviour of this mysterious bat-borne pathogen and global efforts to prepare for potential pandemics. Marburg causes high fever, vomiting, diarrhoea and bleeding from orifices. It spreads between people via direct contact with the blood or other bodily fluids of infected people and with surfaces and materials such as clothing contaminated with these fluids. One of the two outbreaks, in Tanzania in East Africa, seems to have been brought under control, with just two people left in quarantine. But in the other, in Equatorial Guinea on the west coast, spread of the virus is ongoing, and the World Health Organization (WHO) said last week that the country was not being transparent in reporting cases. The WHO said both outbreaks pose regional risks: Equatorial Guinea has porous borders with Cameroon and Gabon, and so far the cases have appeared in geographically diffuse parts of the country. In Tanzania, the Kagera region has busy borders with Uganda, Rwanda and Burundi. Read full story (paywalled) New York Times, 5 April 2023
  17. News Article
    Federal regulators have decided to authorise a second omicron-specific coronavirus vaccine booster shot for people who are at least 65 or have weak immune systems in an effort to provide additional protection to high-risk individuals, according to several officials familiar with the plan. The Food and Drug Administration is expected to announce the step in the next few weeks, and the Centers for Disease Control and Prevention is expected to move quickly to endorse it, said the officials, who spoke on the condition of anonymity because they were not authorised to publicly discuss internal discussions. Eligible individuals will be able to receive the dose as long as it has been at least four months since their first shot of what’s known as the bivalent booster, which targets omicron subvariants BA.4 and BA.5 as well as the original novel coronavirus. The expectation is that consumers will consult with their health-care providers about whether to get the extra booster, the officials said. John P. Moore, a professor of microbiology and immunology at Weill Cornell Medicine in New York, said an extra booster could benefit people who are in poor health or have an impaired immune system. But he was skeptical everyone older than 65 needs it. Boosters lead to “a short-term boost against mild infection but protection against severe disease is still pretty robust” because of previous shots, he said. Read full story (paywalled) Source: Washington Post, 3 April 2023
  18. News Article
    Confirmation the government has cut hundreds of millions from budgets partly designed to boost health and care integration has been met with fury, with the decision described as leaving the social care reform agenda in ‘tatters’. It was revealed last month that the £1.7bn promised in 2021’s social care white paper to strengthen the sector, and especially its contribution to more integrated services, was set to be drastically cut by ministers. Today’s announcement has confirmed the investment originally ear-marked for “investment in knowledge, skills, health and wellbeing, and recruitment policies [to] improve social care as a long-term career choice” has been cut from £500m to £250m, the £300m promised to “integrate housing into local health and care strategies" cut to zero. The white paper also promised “at least £150m” for investment in digital and technology, but today’s government announcement has capped this at £100m. Overall cuts to the series of reform programme are in the region of £600m. Only £520m has been allocated, and it is unclear where the rest of the original £1.7bn will be spent. Sarah McClinton, president of the Association of Directors of Adult Social Services, said the plan “takes us backwards” and “leaves the government’s vision for reform in tatters”, adding that it “ducks the hard decisions and kicks the can down the road again until after the next election.” Read full story (paywalled) Source: HSJ, 4 April 2023
  19. News Article
    The number of new ambulances in England will be far less than the hundreds promised by the government, a Freedom of Information request has revealed. In January, 800 new ambulances were announced, with a 10% fleet increase. But vehicles being ordered by trusts are mostly replacements they were prevented from purchasing because of procurement changes and the pandemic. In response to a written question in February, DHSC said the "over 800 new ambulances" advertised equated to about 350 extra vehicles, plus 100 mental health ambulances. However, the FOI responses from England's ambulance trusts suggest the number of extra vehicles will be far fewer. Read full story Source: BBC News, 4 April 2023
  20. Content Article
    The National Centre for Social Research’s (NatCen’s) British Social Attitudes (BSA) survey has been conducted annually since 1983. Each year the survey asks people what it's like to live in Britain and what they think about how Britain is run, including measuring levels of public satisfaction with the health and care services.  The most recent survey was carried out between 7 September and 30 October 2022 and asked a nationally representative sample (across England, Scotland and Wales) of 3,362 people about their satisfaction with the National Health Service (NHS) and social care services overall, and 1,187 people about their satisfaction with specific NHS services, as well as their views on NHS funding.  This report highlights the key findings of the survey, which was jointly sponsored this year by The King's Fund and the Nuffield Trust.
  21. Content Article
    The number of patients who die from post-surgical complications in low- and middle-income countries is shockingly high. In Africa alone, more than 600,000 people die each year after surgery, mostly from causes that are relatively easy to treat. This blog by Pierre Barker, Chief Scientific Officer at the Institute for Healthcare Improvement (IHI) looks at a method for reducing post-surgical death called the '5Rs for rescue': Risk stratification Recognise deterioration Respond Reassess Reflect/Redesign He describes how the IHI will test how to support the reliable implementation of the '5Rs for Rescue', which aims to reduce mortality by 25%.
  22. 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. Lesley talks to us about how personal stories enrich our understanding of data, drive real quality improvement and remind us that healthcare is all about people. She also explains how her own personal experience drives her work to improve healthcare experiences for patients and their families.
  23. Content Article
    In this BMJ article, consultant in geriatrics and acute medicine David Oliver describes his experience of being an inpatient in the hospital he works in. He talks about how his three-day admission with respiratory syncytial virus and pneumococcus has given him a better understanding of what patients experience in hospital. He describes how lack of privacy, poor quality food and noise affected him during his stay as an inpatient. He also highlights that although all staff were professional and kind, they were clearly overworked and unable to focus on more 'minor' concerns that patients have.
  24. Content Article
    This webinar hosted by the Patients Association looked at the benefits to patients of accessing their GP health records online, and answered questions from patients about how to access this information. 
  25. Content Article
    A just and learning culture is the balance of fairness, justice, learning–and taking responsibility for actions. It is not about seeking to blame the individuals involved when care in the NHS goes wrong, nor the absence of responsibility and accountability. This report by NHS Resolution aims to promote the value of a person-centred workplace that is compassionate, safe and fair.
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