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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. News Article
    A nine-year-old boy died of sepsis eight days after he was discharged from hospital with influenza and sent home with painkillers, an inquest has been told. Dylan Cope was admitted to Grange University Hospital in Cwmbran, South Wales, with abdominal pain but was discharged after a medic “dismissed any concern” about his appendix. Days later the boy had a ruptured appendix and sepsis diagnosed, and he died at the University Hospital of Wales in Cardiff on December 14, 2022. Read full story (paywalled) Source: The Times, 21 May 2024
  2. Content Article
    This Lancet study examines the discrepancy between occurrence of Long Covid as perceived and reported by participants in longitudinal population-based studies and evidence of Long Covid recorded in their EHRs. The authors argue that this discrepancy might reflect substantial unmet clinical need, particularly amongst patients of non-White ethnicity. This is in keeping with reports from individuals with Long Covid of difficulties accessing healthcare, and poor recognition of and response to their illness when they do.
  3. News Article
    Jersey politicians have voted to approve plans to allow assisted dying for those with a terminal illness "causing unbearable suffering". The States Assembly has been debating two routes through which people who have lived in Jersey for longer than a year, are 18 or over and have decision-making capacity could apply for assisted dying. A total of 32 members voted in favour while 14 voted against route one. The second route, for those who are not terminally ill but who have an incurable medical condition causing unbearable suffering, was rejected by a majority of 27 to 19. Plans for legalising assisted dying were voted on in principle by the assembly in 2021, but the aim of the vote was to decide how it could work in practice. With a decision now made, the process for drafting a law could take about 18 months, with a debate then taking place by the end of 2025. If a law is approved, it is expected a further 18-month implementation period would then begin, meaning the earliest for it to come into effect would be summer 2027. Speaking after the debate, Chief Minister Lyndon Farnham said "robust safeguards" would be "enshrined in law." He thanked the assembly for a "thoughtful, respectful and considered" debate. Read full story Source: BBC News, 22 May 2024
  4. Content Article
    The last two decades have seen substantial advancement in the practice of team-based, safe care delivery. In parallel, burnout has been recognised as prevalent among US doctors and influenced by workplace structure and experiences. This study assessed US doctors’ perceptions of team-based care delivery and safety climate within their institutions and how these domains were associated with burnout.
  5. Event
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    Despite being one of the largest economies, the UK suffered the third worst Covid-19 death toll in Western Europe, largely due to entrenched inequalities that were exposed and worsened by the pandemic. The Unequal Pandemic film, executively produced by Debbie Abrahams MP and Good Guys Productions, draws to light the disproportionate impact of the pandemic on marginalised communities. This pre-release screening and panel event, created in collaboration with Covid-19 Bereaved Families for Justice UK and UCL, provides an opportunity for policy makers, bereaved families, experts and all with an interest in protecting lives in the future, to take stock of what went wrong, and what can and must be done to make sure the UK is better prepared when the next pandemic hits. We hope this event will allow us to gather and learn from the experiences of experts, government workers and community members, and help us forge a practical path towards pandemic preparedness. Watch The Unequal Pandemic Film trailer. Chair Prof Ibrahim Abubakar, Pro-Provost (Health) at UCL and Dean for the Faculty of Population Health Sciences Speakers Prof Sir Michael Marmot, Director, UCL Institute of Health Equity Debbie Abrahams MP, Executive Producer of 'The Unequal Pandemic' Lobby Akinnola, Spokesperson for Covid-19 Bereaved Families for Justice UK whose personal story is featured in the film Prof Naomi Fulop, Professor of Health Care Organisation and Management, UCL and a Director, Covid-19 Bereaved Families for Justice UK
  6. News Article
    The number of people sent out of their home area for a mental health bed – in some cases hundreds of miles away – has increased to a five-year high, despite national ambitions to eliminate the practice. A 2021 date to stop “inappropriate out of area placements” was initially set by government and NHS England in 2016 but, despite initial reductions, the target was missed, with hundreds of patients still affected each month. Demand and bed pressures in the wake of covid appeared to make it more difficult and numbers have been rising. Analysis of the latest NHS Digital data this month shows 825 active inappropriate placements in February 2024 following a steady rise from December 2023, when there were 700 (see chart). The year on year increase from February last year is 15 per cent, but there has been a 46 per cent rise since a low of 565 just 14 months previously, in December 2022. Being sent out of area can disrupt the patient’s care, make it less likely patients will be visited, harder for them to return home and to community support, and is also often very expensive as places are bought at short notice from independent providers. NHSE acknowledged pressures on OAPs in 2024-25 planning guidance but asked systems to “work towards” eliminating them, saying they are “detrimental to patient safety, experience and outcomes.” National mental health director Claire Murdoch last month told HSJ they represented “poor care at relatively high costs.” Read full story (paywalled) Source: HSJ, 23 May 2024
  7. News Article
    Patients taking antidepressants are being warned to beware of side-effects that could leave them 'asexual' even after they stop using them - a problem that could affect millions of Brits. Selective serotonin reuptake inhibitors (SSRIs), the most common class of antidepressant drug in the UK, are relied upon by one in eight Brits - 8.6million in all - who are dealing with mental health issues like anxiety and depression. Common SSRIs prescribed in the UK include citalopram, fluoxetine and sertraline, sometimes known by brand names Cipramil, Prozac and Lustral - but their use has been linked to long-term and even permanent sexual dysfunction by researchers. The NHS has warned that side effects such as a loss of libido and achieving orgasm, lower sperm count and erectile dysfunction 'can persist' after taking them - and patients have described feeling 'carved out', relationships wrecked, from their use. Men and women say SSRI side-effects have hampered their sex lives, even after coming off of the medications - a condition known as Post-SSRI Sexual Dysfunction (PSSD), which is not officially recognised by UK health authorities. For millions, antidepressants can be a life-saving drug - but the authors of a US petition urging more warnings to be applied to the drugs say it can be 'impossible... to weigh the benefits of treatment against the harms'. Read full story Source: Daily Mail, 23 May 2024 Read this opinion piece on the hub by someone who suffers from post-SSRI sexual dysfunction (PSSD) after he was prescribed a selective serotonin reuptake inhibitor. The author calls for widespread recognition, improved risk communication and better support for sufferers. If you have experience of PSSD, you can also share your insights in our community discussion.
  8. Event
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    The session will explore the system wide risks involved in prescribing through reference to clinical negligence claims from NHS Resolution and the panel firm, Hill Dickinson. Event programme The invaluable role of pharmacists Common medicine error claims Recommendations Q&A panel discussion Contributors Joanne Hughes – Partner | Hill Dickinson Dr Anwar Khan – Senior clinical advisor | NHS Resolution Register for the webinar 20240703 Dispelling the myth-towards safer practice flyer.pdf
  9. Event
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    NHS Resolution’s Safety and Learning team, in collaboration with HSSIB and NHS England are hosting a virtual forum on the benefits of implementing safety science in primary care, responding to patient safety incidents and the support available to staff working in general practice and primary care. Event programme How claims data can support us | NHS Resolution Patient safety education offer and the role of HSSIB in primary care | Health Services Safety Investigations Body Primary care patient safety strategy | NHS England Q&A panel discussion Contributors Andrew Murphy-Pittock – Education director | Health Services Safety Investigations Body Dr Kiren Collison – Deputy medical director for primary care | NHS England Hester Wain – Head of patient safety policy | NHS England Samantha Thomas - National safety and learning lead for General Practice (Midlands and North) | NHS Resolution Register for the webinar Benefits in primary care webinar.pdf
  10. News Article
    Having an epidural during labour can reduce the risk of serious childbirth complications by 35%, according to research that suggests expanding access to the treatment may improve maternal health. An epidural is an injection in the back to stop someone feeling pain in part of their body. Making them more widely available and providing more information to those who would benefit from one was even more important than previously thought, researchers said. The study by the University of Glasgow and the University of Bristol involved 567,216 women who were in labour in Scottish NHS hospitals from 2007 and 2019, and went on to give birth vaginally or by an unplanned caesarean section. Of the total, 125,024 of the women had an epidural. Researchers analysed the rate of serious complications, including heart attacks, eclampsia, and hysterectomies during childbirth. Having an epidural cut the risk of these events by 35%, the study found. The lead author, Prof Rachel Kearns, of the University of Glasgow, said: “This finding underscores the need to ensure access to epidurals, particularly for those who are most vulnerable – women facing higher medical risks or delivering prematurely. “By broadening access and improving awareness, we can significantly reduce the risk of serious health outcomes and ensure safer childbirth experiences.” Read full story Source: The Guardian, 22 May 2024
  11. News Article
    Patients could be put at risk by plans to allow local NHS bodies to oversee the quality of health screening programmes for diseases such as breast and bowel cancer, experts have suggested. At the moment, NHS England runs the Screening Quality Assurance Service (SQAS) to make sure local organisations comply with national standards, are safe and can be subject to inspections. There are 11 national screening programmes in England, including those for breast, cervical and bowel cancer, plus antenatal and newborn screening, abdominal aortic aneurysm and diabetic eye screening. At the moment, screening programmes must report all safety incidents to the SQAS and the SQAS inspectors visit local sites to pick up urgent issues and make recommendations. Now, a report in the British Medical Journal questions plans by NHS England to allow local bodies to have more control. Sue Cohen, former national lead of screening quality assurance at Public Health England, told the BMJ that devolving responsibility for SQAS to local organisations would be a “retrograde” step. She pointed to previous issues, such as in Kent where a lack of oversight of a cervical screening programme led to women with cancer not being picked up. She said: “If you don’t have a quality assurance service that is properly resourced and has that ability to keep a national view, you will simply not have the oversight of the system and there is a bigger risk of incidents going undetected.” Read full story Source: Medscape News, 22 May 2024
  12. News Article
    Children with mental health illnesses are forced to stay in wards not fit to care for them with patients warning these hospital stays are like a “form of torture”, an NHS safety watchdog has found. Children with mental health conditions were admitted to general hospital wards, not intended for mental health care, nearly 44,000 times in 2021 and 2022, the Health Services Safety Investigation Body has warned. These wards which are “noisy, busy and brightly lit” are not often appropriate for these children who require mental healthcare and are unable to keep them safe, HSSIB said in a report on Thursday. The watchdog is calling for new guidance for hospitals on how to adapt their general paediatric wards for children who have mental health support needs. In a new investigation, the watchdog said it found in some hospitals patients were placed in rooms with “little or no consideration of therapeutic elements” which are “stripped of everything” including window blinds and shower curtains. In one hospital, staff said even the mattresses are removed. Between 2021 and 2022 11.7 per cent, or 39,926 admissions to paediatric wards, for physical health, were for children who had a mental health condition. Read full story Read HSSIB investigation report – Keeping children and young people with mental health needs safe: the design of the paediatric ward (23 May 2024) Source: The Independent, 23 May 2024
  13. News Article
    Dental graduates in England could be forced to work in the NHS to help tackle the crisis in access that has left millions struggling to get their teeth repaired. Under the government’s plan they would have to undertake NHS work for “several years” after leaving university or face paying back some of the £200,000 cost of training them. A fall in the number of dentists doing NHS work has helped create “dental deserts”, where patients cannot get treatment, and prompt some people to turn to “DIY dentistry”, including pulling their own teeth out. However, the British Dental Association (BDA), which represents dentists, claimed ministers were seeking to “shackle graduates to a service facing collapse” and said the plan would do little to improve access to NHS care. Victoria Atkins, the health secretary, said: “Taxpayers make a significant investment in training dentists, so it is only right to expect dental graduates to work in the NHS once they’ve completed their training.” Read full story Source: The Guardian, 23 May 2024
  14. Content Article
    This cross-sectional study in JAMA Network Open aimed to explore whether prescribing of psychotropic medications for children and adolescents changes in the two years following the onset of the Covid-19 pandemic. The authors retrieved and analysed all 8,839,143 psychotropic medication prescriptions dispensed to individuals aged from 6 to 17 years in France between 2016 and 2022. They found steady increases in prescription trends for all psychotropic medications after the pandemic onset, with prescription rates of all psychotropic medication classes except psychostimulants higher than expected rates.
  15. Content Article
    In this Byline Times article, the family of 18 year-old Mollie McAinsh describe her treatment in an NHS hospital after they sought help for her life-limiting ME. Millie developed the condition after a viral illness in 2019 and became increasingly unwell. When she was no longer able to feed herself, she was admitted to the Royal Lancaster Infirmary, where her family believed she would have a feeding tube fitted and then be sent home. However, while in hospital her mother was banned from visiting and Millie was sectioned under the Mental Health Act. The article looks at the issues facing people with severe ME and examines the history of how the illness has been perceived, which many believe has resulted in the wrong treatment being offered to ME patients.
  16. Content Article
    This webpage outlines the role of the Patient and Client Experience team at the Northern Ireland Public Health Agency. The team analyses the experiences of patients, clients, carers, relatives (collectively referred to as service users) and staff through a number of tested data collection methods. The two main methods are: Care Opinion This is an online user feedback system providing a platform for services users to share feedback on services they have engaged and to share what is important to them. The system supports two-way feedback between the service user and service staff and allows for analysis of the experience from service level supporting local service improvement, to regional strategic learning to influence commissioning and service development. 10,000 More Voices This initiative supports in depth analysis of experience using service user narrative and software called “Sensemaker®”. Sensemaker captures and orders the thinking of people’s attitudes, perceptions and experiences within a complex culture. The workplan for 10,000 more voices is informed by strategic programmes and feedback from other sources (such as Care Opinion/complaints/incident) to look deeper at the issues and the experience of a defined service or process.
  17. Content Article
    This handbook produced by the Healthcare Financial Management Association (HFMA) is designed to help NHS governing bodies and audit committees in reviewing and reassessing their system of governance, risk management and control. This is to make sure the governance remains effective and fit for purpose, whilst also ensuring that there is a robust system of assurance to evidence it.
  18. Content Article
    Patients’ waits do not begin when the NHS clock starts—on referral to a consultant. They begin when the person decides their symptoms merit professional attention. In this blog, Sue Brown, CEO of the Arthritis and Musculoskeletal Alliance (ARMA) looks at the patient’s experience of waiting and how it differs from the NHS understanding. She argues that if the NHS is to deal with waiting lists well, it needs to understand what waiting means to patients.
  19. Content Article
    Home dying is a policy indicator of ‘quality dying’ in many high-income countries, but there is evidence that people living in areas of higher deprivation have a reduced likelihood of dying at home. However, there is limited research which centres the views and experiences of people living with both socioeconomic deprivation and serious advanced illness. This study used visual methods to address this gap in knowledge, focusing on barriers to and experiences of home dying for people experiencing poverty and deprivation in the UK. The authors used photovoice and professional documentary photography between April 2021 and March 2023 with eight participants with serious advanced illness, six of whom had died by the end of the study. They also worked with four bereaved family members to create digital stories.
  20. Content Article
    In this long read, inews health correspondent Paul Gallagher looks at the processes now in place to ensure patient safety in blood transfusions and mitigate the risk of another infected blood scandal. He talks to Will Irving, Professor of Virology at the University of Nottingham, who outlines at although the risk is low, there may be transmission risks associated with blood transfusions that we are not yet aware of. The article also describes the work of the Serious Hazards of Transfusion (SHOT) committee, which has been collecting and analysing anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations that are involved in the transfusion of blood and blood components in the UK since 1996.
  21. News Article
    England's patient safety commissioner says her calls for changes following failings highlighted in three health scandals are "falling on deaf ears". Dr Henrietta Hughes made the comments at a meeting in Westminster on Tuesday of MPs and campaigners of medical scandals. It comes after Sir Brian Langstaff's highlighted a decades-long "subtle, pervasive, chilling" cover-up by successive governments and the NHS in the conclusion of his report on the infected blood scandal. Like the victims of that scandal, those affected by epilepsy drug Valproate, as well as vaginal mesh implants, and the hormone pregnancy test Primodos, are also waiting on the government to implement a redress scheme. The three campaign groups have already had a combined review. In July 2020, the Cumberlege review found similar failings to the blood scandal: damaging products, poor regulatory decisions, and one government after another refusing to accept wrong had been done. In February this year, the patient safety commissioner set out her "blueprint" of a redress scheme for victims. However, Ms Hughes, who attended the First Do No Harm All Parliamentary group meeting, said on Tuesday: "I'm itching to get the changes that are needed, but I feel my words are falling on deaf ears." Read full story Source: Sky News, 21 May 2024
  22. News Article
    An artificial intelligence (AI) system that sends text messages to alert hospital physicians about the high risk for mortality in their patients reduces the number of deaths, according to a study published in Nature Medicine. Chin-Sheng Lin, PhD, associate professor of cardiology at the Tri-Service General Hospital of the National Defense Medical Center in Taipei, Taiwan, and his colleagues have developed an AI system that identifies patients with a high risk for mortality on the basis of a 12-lead ECG. The system is intended to identify patients who would benefit from intensified care. "It is widely acknowledged that providing intensive care to critically ill patients reduces mortality. Delays in providing intensive care for critically ill patients result in catastrophic outcomes. Most in-hospital cardiac arrests are potentially preventable; however, the early signs of deterioration might be difficult to identify," wrote the researchers. The authors emphasized that exactly how the AI warning messages lead to a decrease in overall mortality must still be clarified. But the results suggest that they help in detecting high-risk patients, triggering timely clinical care, and reducing mortality, they wrote. Read full story Source: Medscape, 21 May 2024
  23. News Article
    Attacks on health workers, hospitals and clinics in conflict zones jumped 25% last year to their highest level on record, a new report has found. While the increase was largely driven by new wars in Gaza and Sudan, continuing conflicts such as Ukraine and Myanmar also saw such attacks continue “at a relentless pace,” the Safeguarding Health in Conflict coalition said. Researchers recorded more than 2,500 incidents of “violence against or obstruction of healthcare” in 2023, including the killing or kidnapping of health workers and the bombing, looting and occupation of hospitals. The coalition called for national and international prosecutions of “war crimes and crimes against humanity involving attacks on the wounded and sick, health facilities and health workers.” Its report highlighted cases of attacks on children’s hospitals and sites running immunisation campaigns, leaving people vulnerable to infectious diseases. It also warned of a new trend in which drones armed with explosive weapons are used to target health facilities. Leonard Rubenstein, of the Johns Hopkins school of public health, who chairs the coalition, said violence inflicted on healthcare workers and facilities had “reached appalling levels”. The report included examples where workers had been deliberately targeted, and others where combatants were reckless or indifferent to the harm caused, he said. “The lack of restraint we are seeing, from the beginning of conflicts, suggests to me that the law on protecting healthcare has had no meaning to combatants.” Read full story Source: The Guardian, 22 May 2024
  24. News Article
    A former Team GB rower claims a treatment she underwent for long Covid leaves participants feeling "blamed" for being ill. Oonagh Cousins was offered a free place on a course run by the Lightning Process, which teaches people they can rewire their brains to stop or improve long Covid symptoms quickly. Ms Cousins, who contracted Covid in March 2020, said it "exploits" people. However, the programme's founder denied it blames patients for their illness, saying that was completely at odds with the concepts of the programme Ms Cousins had reached a career goal many athletes can only dream of - being selected for the Olympics - when she developed long Covid. By the time the cancelled 2020 Olympic Games in Tokyo were rescheduled for 2021, Ms Cousins was too ill to take part. When she went public with her struggles, she was approached by the Lightning Process. It offered her a free place on a three-day course, which usually costs around £1,000. "They were trying to suggest that I could think my way out of the symptoms, basically. And I disputed that entirely," the former rower said. "I had a very clearly physical illness. And I felt that they were blaming my negative thought processes for why I was ill." She added: "They tried to point out that I had depression or anxiety. And I said 'I'm not, I'm just very sick'." Prof Danny Altmann, a leading long Covid researcher, says such behavioural approaches disregard the "mass" of underlying damage in patients that can be measured in tests. Read full story Source: BBC News, 21 May 2024
  25. News Article
    The chief executive of an acute trust operating in one of the country’s most troubled healthcare economies has admitted his organisation is struggling to get the most from its top of the range electronic patient record system three years after rollout. Royal Devon University Healthcare Foundation Trust implemented the Epic EPR in October 2020, but the system is still causing problems with reporting performance. In an interview with HSJ, chief executive Sam Higginson described Epic as a “Rolls-Royce of an EPR”, but he added: “For lots of different reasons we’re still driving it a little bit like it’s a Ford Focus. He added: “We assumed by installing an EPR that basically it would have a sufficient level of functionality that we could switch off pretty much everything else. But then you find actually it doesn’t quite have the functionality you thought it did, or you don’t quite know how to use it.” However, Mr Higginson said the trust’s use of the EPR was improving “every month”, and the trust is testing a new cancer reporting module which it hopes will resolve the reporting problems. Read full story (paywalled) Source: HSJ, 21 May 2024
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