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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Against the backdrop of the Covid-19 pandemic, ensuring the safety of health and social care services remains a serious, ongoing challenge. This report examines how patient safety governance mechanisms in Organisation for Economic Co-Operation and Development (OECD) countries have withstood the test of Covid-19. It provides recommendations for further improving patient safety governance and strengthening health system resilience in OECD countries. This working paper was produced by the OECD for the 5th Global Ministerial Summit on Patient Safety, held in Montreux, Switzerland in February 2023.
  2. News Article
    Thousands of patients are being forced to wait more than 18 months for treatments such as knee and brain surgery as the health service is set to miss its flagship target because of NHS strikes. NHS England last week claimed it was “on track” to hit the mandated target, but senior sources have warned that the impact of prolonged walkouts combined with unprecedented demand for emergency care means that this is now unlikely. The sources say it is probable that up to 10,000 patients will still be waiting for 18 months or more by the end of March, as a knock-on effect of the cancellation of 140,000 appointments because of strike action. More walkouts are planned over the coming weeks. Patricia Marquis, RCN director for England, said the backlog was “yet even more evidence of what happens when you fail to invest in the workforce. If ministers are serious about preventing a further exodus and cutting the backlog, they need to hear the calls of NHS leaders and come to the table and talk about pay. Only then will patients receive the care they need and waiting lists start to come down.” Read full story Source: The Independent, 15 February 2023
  3. Content Article
    This National Workforce Implementation Plan outlines a series of practical actions that will act as enablers to accelerate the Welsh Government's ten-year vision for its Workforce Strategy. It addresses the following issues:Governance and accountabilityWhat does our workforce look like now?What will our workforce of the future look like?Fill the workforce gapsRetain our workforce: Engage, support and developPlan for the future
  4. Event
    The implementation of policies from the centre, getting systems talking to each other and bridging the gap between analysts and clinicians all remain system-wide issues. The HSJ Data & Analytics Forum is a unique opportunity to challenge thinking, discuss challenges openly and share best practice through a blend of keynote speeches, panel sessions and intimate round-table discussions. Register for this event
  5. News Article
    GPs are attempting to deal with up to 3,000 patients each, amid worsening staff shortages, according to new analysis commissioned by the Liberal Democrats. The research shows that the number of patients per GP has risen sharply, as rising numbers of doctors reduce their hours, or opt for early retirement. The figures, which track the number of “full-time equivalent” fully qualified GPs, show the number has fallen from 29,320 in 2016 to 27,372 last year. The trend follows a rise in part-time work, with the average GP now working a three-day week. On average, there are now 2,273 patients per fully qualified doctor, up from 1,981 in 2016, the research commissioned by the Liberal Democrats shows. While the total number of GPs fell by almost 2,000, the number of registered patients grew from 58 million to 62.2 million, according to the House of Commons Library. Professor Kamila Hawthorne, chairwoman of the Royal College of GPs, said the research “shows yet again how GPs and our teams are working above and beyond to deliver care to an ever-growing patient population, with falling numbers of fully qualified, full-time equivalent GPs.” Read full story (paywalled) Source: The Telegraph, 14 February 2023
  6. News Article
    A health board has been fined £180,000 for failing to protect a vulnerable pensioner who died after repeatedly falling in hospital. Colin Lloyd, 78, was assessed as posing a high risk of falling and required one-to-one care after being admitted to Raigmore Hospital in Inverness. Despite repeated requests for more nursing staff none were made available and the pensioner suffered falls on the ward, which caused fatal injuries. Fiona Hogg, NHS Highland’s director of people and culture, said: “We are deeply sorry for the failures identified in our care. Our internal review following the incident identified several areas of improvement and we have made a number of changes to our practice.” Read full story (paywalled) Source: The Times, 15 February 2023
  7. News Article
    The number of GPs seeing patients outside standard surgery hours in Scotland has dropped by almost a quarter in three years. Nurses and paramedics have had to fill in for doctors in the out-of-hours urgent care centres because GPs could not be found to cover the shifts. Some health boards have had to close their centres and send patients to overstretched A&Es instead because of the GP shortage. Dr Andrew Buist, chairman of the British Medical Association’s Scottish GP committee, said, “Patient demand is outstripping GP capacity across the whole service, including out-of-hours. We simply do not have enough GPs in Scotland. Those who are working in out-of-hours may be doing more hours now than they perhaps did in 2019 which comes as no surprise if there are fewer GPs to go around but it is unsustainable and puts those working in the service at risk of exhaustion and burnout.” Read full story (paywalled) Source: The Times, 15 February 2023
  8. News Article
    Healthcare leaders have been warned by nearly 200 doctors that plans to give more work to private hospitals will “drain” money and staff away from NHS services, leaving the most ill patients at risk. In a letter seen by The Independent, almost 200 ophthalmologists urged NHS leaders to rethink plans to contract cataract services to private sector hospitals, as to do so “drains money away from patient care into private pockets as well as poaching staff trained in the NHS”. The doctors have called for “urgent action” to stop a new contract from being released, which would allow private sector hospitals to take over more cataract services. Professor Ben Burton, consultant ophthalmologist and one of the lead signatories of the letter, said, “What is needed is a long-term sustainable solution rather than a knee-jerk reaction which risks the future of ophthalmology as an NHS service. The long-term solution will be achieved by investing in NHS providers to deliver modern, efficient care, and the private sector only used as a last resort.” Read full story Source: The Independent, 10 February 2023
  9. News Article
    Some doctors say that however reasonable guidelines may seem, their cumulative burden causes “constant frustration” to medical practice. A team of doctors wrote a study last year for the Journal of General Internal Medicine which suggested that if an American doctor followed all of the guidelines for preventive, chronic and acute disease care issued by well-known medical groups, it would require nearly 27 hours per day. Guidelines have become “a constant frustration,” said Dr. Minna Johansson, a general practitioner in Uddevalla, Sweden, who also directs the Global Center for Sustainable Healthcare at the University of Gothenburg. “A lot of guidelines may seem reasonable when considered in isolation, but the cumulative burden of all guideline recommendations combined is absurd.” Read full story (paywalled) Source: New York Times, 14 February 2022
  10. News Article
    Around half of the largest trusts are not buying all their electricity from renewable sources despite a national requirement to do so, as prices of this type of energy rocket. NHS England previously committed to the service purchasing only renewable energy from April 2021, as part of efforts to meet its target to be net zero for emissions it can control–including electricity–by 2040. However, NHSE information seen by HSJ shows that nine of the largest 20 trusts have not been buying 100 per cent renewable electricity this financial year, amid soaring costs. Several trusts told HSJ they had abandoned previous decisions to only use electricity which was “guaranteed” to be renewable. Read full story (paywalled) Source: HSJ, 15 February 2023
  11. Content Article
    NHS chairs and non-executive directors play a key role in driving forward transformational change across the health and care sectors. As a vital leadership group they hold executive teams to account and in doing so build patient, public and stakeholder confidence in the NHS. The NHS North West Leadership Academy (NHS NWLA) have curated a range of development support and useful resources tailored to support those in non-executive roles. This webpage contains information on: system leadership modules NHS NWLA Executive Coaching leadership masterclasses the Non-executive Leaders Network the Next Director scheme. It also contains links to the following reports and resources: Non-executive directors and integrated care systems: What good looks like Strengthening NHS board diversity Healthcare Leadership Model (HLM) self-assessment and 360 feedback System leadership behaviours framework and conversation cards Healthy leadership framework.
  12. Content Article
    NHS Providers offers a board development programme that aims to improve the effectiveness of NHS boards and organisations through practical, interactive training and development delivered by expert trainers with extensive senior-level sector experience. This webpage contains information about the board development programme including: core training modules. in-house training. induction programmes. bespoke development programmes.
  13. Content Article
    In this blog, US family doctor Lisa Baron highlights the role that social media has played in exposing how patients, particularly women, are dismissed and gaslighted by healthcare professionals, resulting in delayed diagnosis, deterioration and trauma. She talks about her own experience of having her symptoms and concerns dismissed by her GP, which led to a two-year delay in being diagnosed with coeliac disease, rheumatoid arthritis and Sjogren's syndrome. She goes on to talk about her experience of Long Covid and how her symptoms were dismissed and not taken seriously in spite of the life-limiting nature of her condition. She raises concerns that Long Covid patients are turning to unqualified practitioners offering untested, ineffective and expensive treatments as they are not being taken seriously by mainstream healthcare systems.
  14. Content Article Comment
    Glad you enjoyed the article Chris, if you would like to share any of your own perspectives from the US, we'd love to hear them.
  15. Content Article
    Self-binding directives instruct clinicians to overrule treatment refusal during future severe episodes of illness. These directives are promoted as having the potential to increase autonomy for individuals with severe episodic mental illness. Although lived experience is central to their creation, the views of service users on self-binding directives have not been seriously investigated. This study in The Lancet Psychiatry aimed to explore whether reasons for endorsement, ambivalence or rejection given by service users with bipolar disorder can address concerns regarding self-binding directives, decision-making capacity and human rights.
  16. Content Article
    This article in Nurse Leader examines mounting evidence for nurse and patient safety associated with registered nurse (RN) fatigue. What changes driven by strong evidence are nursing leaders enacting to reduce the impact of RN fatigue on patient and nurse safety?
  17. Content Article
    Storytelling gives a voice to patients and staff as well as providing an opportunity for others to understand the importance of patient safety from the perspectives of those that access services or work within them. This toolkit was developed by the National Quality and Patient Safety Directorate in Ireland which works in partnership with health services, patient representatives and other partners to improve patient safety and quality of care. It provides a step by step guide to creating patient and staff stories.
  18. Content Article
    In this episode of The Human Risk podcast, host Christian Hunt speaks to Dr Gordon Caldwell, a retired NHS Consultant and Clinical Lead about the impact of medical bureaucracy. In 2019, Gordon had a photograph taken of himself lying next to a long line of forms, to highlight the amount of paperwork healthcare professionals need to fill in. Gordon is a campaigner against bureaucracy, and he wanted to make the point that time spent filling in forms is time spent not looking after patients. In the podcast, Christian and Gordon discuss: the genesis of the photograph and why Gordon felt motivated to take it the reasons why there is so much bureaucracy within the NHS the impact this has on patient care what Gordon sees as ways to improve it. See also: The Spectator: The NHS is drowning in paperwork Pictured: Doctor shows army of ‘pointless’ forms burying NHS hospitals
  19. Content Article
    This article explains the emerging role of simulation in improving quality and safety. It is part of the Cambridge University Press 'Elements of Improving Quality and Safety in Healthcare' series. The article covers: Healthcare Simulation as an Improvement Technique Definition and Description of Healthcare Simulation How Simulation Became Integrated into Approaches to Improve Quality and Safety Simulation in Action Exploring Working Environments and the Practices and Behaviours of Those in Them Improving Clinical Performance and Outcomes Testing Planned Interventions and Infrastructural Changes Helping Healthcare Professionals to Learn about and Embed a Culture of Improvement Critiques of Simulation Is Simulation an Effective Technique for Improvement? How Should We Integrate Simulation into Healthcare Improvement? Can We Build a Business Case for Simulation?
  20. Content Article
    This Sky News investigation looks at one of the pharmaceutical industry's biggest scandals—the hormone pregnancy test Primodos which was prescribed to pregnant mothers in the UK between 1958 and 1978. Primodos was found to lead to birth defects, miscarriages and stillbirth, and regulatory failings led to avoidable harm to thousands of babies.
  21. Content Article
    Incomplete or inaccurate recording of ethnicity will undermine attempts to address health inequalities and improve access, experience and outcomes for Black, Asian and minority ethnic communities. This report by the Race Equality Foundation and the Office for National Statistics (ONS) looks at different aspects of the recording of ethnicity in healthcare. The authors interviewed people from a range of communities across England, as well as healthcare workers from different areas and settings to understand both sides of the process of collecting ethnicity data.
  22. Content Article
    For years, it has been known that pulse oximeters may present racial biases, with studies dating back as far as the late 1980s suggesting a flaw in how the device measures oxygen in people with darker skin tones. This article looks at how the Covid-19 pandemic finally brought the problem to the forefront of medicine. Ashraf Fawzy, Assistant Professor of Medicine at the Johns Hopkins University School of Medicine, talks about how he and other doctors noticed a trend in pulse oximeter readings not matching up to patient symptoms, and how they went on to research the issue, publishing their results in a study in May 2022. Their study found that Black and Hispanic patients were 29% and 23% less likely than white patients, respectively, to have pulse oximeters recognise their eligibility for more aggressive Covid-19 treatment. The resulting delay in care for patients with darker skin tones is likely to have a significant impact on patient outcomes.
  23. Content Article
    Based on data from 22,132 patients who had emergency bowel surgery in England and Wales between December 2020 and November 2021, this report from the National Emergency Laparotomy Audit (NELA) found that improvements in in-hospital mortality have levelled off. As such, it calls for hospitals to continue to engage with NELA data collection and, in particular, to make use of real-time data and resources available to drive clinical and service quality improvement.
  24. Content Article
    This report by The Queen's Nursing Institute presents the findings of a survey of community nurses (also known as district nurses) conducted in 2022 to look at how digital technologies are used in community nursing. The survey found that: 43.1% respondents reported problems with lack of compatibility between different computer systems, compared to 32.7% in 2017 87% respondents reported issues with mobile connectivity, compared to 85% in 2017 53%.respondents reported problems with device battery life, compared to 29.5% in 2017 The report concludes that overall, the community nursing workforce has a high level of digital literacy and that poor user experience frequently appears to be around design and function rather than a lack of literacy or enthusiasm for technology. The workforce also has an appetite for high functioning technology and can see the potential of new applications, for example, in managing wound care or long-term conditions.
  25. Content Article
    This guidance from the Office of Rail and Road outlines how to manage the risk of fatigue that may arise from a working pattern. It defines 'fatigue factors', highlighting that the more a working pattern features these fatigue factors, the greater the likely need to assess, avoid and control potential fatigue risks.
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