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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    In this article, Rachel Star Withers shares her account of receiving electroconvulsive therapy to treat her severe depression and schizophrenia while in her final year at college. She describes how the treatment robbed her of her memory, reading and writing abilities, but saved her life. Without ECT, Rachel believe she would have committed suicide. She talks about the need to educate people about the realities of ECT and undo unhelpful 'horror-story' stereotypes.
  2. Content Article
    This article by The Health Foundation looks at an evaluation carried out by Warwick Business School of a partnership between The Virginia Mason Institute and five NHS trusts. The partnership aimed to develop a ‘lean’ culture of continuous improvement which puts patients first by developing a localised version of the Virginia Mason Production System in each of the trusts. The objective was to embed and sustain a culture of continuous improvement capability within each of these five trusts and the NHS more broadly.  Outcomes from the evaluation include insight on progress and achievements in each trust, helping them to further embed a culture of improvement capability. The learning will also enable systems leaders to maximise knowledge on how to support providers to embed and spread a culture of continuous improvement in the NHS.
  3. Content Article
    This report from the National Oesophago-Gastric Cancer Audit (NOGCA) focuses on the care received by patients diagnosed with invasive epithelial cancer of the oesophagus, gastro-oesophageal junction (GOJ) or stomach, or high-grade dysplasia (HGD) of the oesophagus between April 2019 and March 2021. For outcomes of curative surgery among people with OG cancer, data are reported for a three year period (April 2018 to March 2021).
  4. Content Article
    This article in iNews looks at a major new study in The BMJ by researchers in Israel which suggests that symptoms of Long Covid end within a year in most people with the condition. The study looked at information on a number of symptoms linked to Long Covid, including loss of taste and smell, breathing problems, concentration and memory issues, weakness, palpitations and dizziness. The research also demonstrated the role of Covid vaccines in improving outcomes for people with Long Covid. However, the article also highlights cautions from experts who note that people who got Long Covid after a more serious case of the virus were not included in the study, and their symptoms typically last longer than for those who got the condition after a mild infection. The authors also highlight that these results do not match up with the latest data from the Office for National Statistics (ONS). According to the ONS, 57% people reporting symptoms in December 2022 said that they had had long Covid symptoms for at least one year, with 30 per cent reporting that symptoms had lasted for at least two years.
  5. Content Article
    This document is Solent NHS Trust's engagement and inclusion strategy, which outlines the Trust's vision to health and reduce inequalities in the community it serves. Developed in partnership with local people, it describes the Trust's commitment to bring together three key things that help improve health: Diversity and inclusion–applying a positive approach to improving access, experience and outcomes for all. People participation–putting people central to decision making at all stages, phases and levels of their health care and healthcare provision as a whole. Community engagement–understanding what our local community does best, what they may need some help from us with and what we need to focus our expertise and energies on.
  6. Content Article
    This report from the National Asthma and COPD Audit Programme (NACAP) offers a view of the care of people with asthma and COPD in England and Wales, and is informed by 103,194 case records submitted to the audit programme. It is the first report to combine data on asthma, COPD and pulmonary rehabilitation across primary and secondary care services to underpin key messages, optimising respiratory care across the pathway.
  7. Content Article
    The Fracture Liaison Service Database (FLS-DB) collects, measures and reports on the care provided by Fracture Liaison Services (FLSs). This annual report presents the results of secondary fracture prevention care received by patients aged 50 and older following a fragility fracture between January and December 2021. Based on 70,384 patient records in 2021 (compared with 70,614 in 2019), it found that there has been a reduction in both case identification and assessment performance, but an improvement in treatment recommendation, monitoring and follow up, when comparing national data from 2021 with 2019.
  8. News Article
    A Conservative MP has blamed “far too many overpaid and utterly useless senior managers” for what he described as the “shambles of the NHS.” Philip Davies, MP for Shipley in Yorkshire, said in an email that the NHS is “appallingly run”, with many senior managers “who wouldn’t be able to get a similar job in the private sector.” He claimed the NHS “shambles” “is not a problem created by the government,” as “the government’s job is to fund that NHS,” while running the services is done by NHS England and individual trusts. However, recent analysis indicates that managers make up just 2 per cent of the NHS workforce, compared with 9.5 per cent of the UK workforce. NHS Confederation has said the NHS is “as a whole under, not over, managed,” despite “persistent and misleading media headlines.” Read full story (paywalled) Source: HSJ, 16 January 2023
  9. Content Article
    In this letter to Steve Barclay MP, Secretary of State for Health and Social Care, the chair and chief executive of the Patients Association, Sir Robert Francis and Rachel Power, raised their concerns about how the Government is dealing with the growing crisis in health and social care. The letter asked him to declare a national incident in the NHS and to publish solutions to the current crisis, developed with patients and carers. The letter also asked the Minister to publish the long-term workforce plan and includes an offer from the Patients Association to work with the Department for Health and Social Care (DHSC).
  10. Event
    until
    The Patients Association Chief Executive Rachel Power will be in conversation with Aisha Farooq, board member on the Children and Young People's (CYP) Transformation Programme at NHS England, as part of the organisation's birthday celebrations. Aisha is a passionate advocate for children and young people. She works to encourage more young people to have their say about health services, as well as encouraging the health system to partner with children and young people. In addition to her position on the CYP Transformation Programme, Aisha is also a young governor at University Hospitals Bristol and Weston Trust, Public Patient Voice Partner on the CYP asthma work stream at NHS England, trustee for the charity Coeliac UK, a member on NICE Expert Panel and a past member of the National NHS Youth Forum. Aisha is currently in her third year studying pharmacology at the University of Bristol. Join us on the 25th to hear about Aisha's journey into advocacy, the importance of listening to young people, and what healthcare in the future might be like. There will be opportunities to ask questions during the webinar. Register your interest
  11. Content Article
    This blog by Robert Otto Valdez, Director of the US Agency for Healthcare Research and Quality (AHRQ), outlines the setbacks to patient safety and the healthcare workforce caused by the Covid-19 pandemic. He highlights areas of concern including workforce burnout and an increase in healthcare associated infections (HAIs) since 2020. The issues faced by the US healthcare system are not felt equally, and Valdez draws attention to a report that demonstrates worsening health inequalities. The blog includes links to evidence-based research and initiatives developed by AHRQ aimed at improving current patient safety priorities. Toolkits to improve antibiotic use. These resources are based on a “Four Moments of Antibiotic Decision Making” model that has shown success in hospitals, long-term care facilities, and ambulatory care practices. Tools to engage patients and families in making healthcare safer. Patients and families are powerful partners in improving quality and safety in hospital settings, during primary care visits, or whenever a diagnosis is made. These resources help ensure that patients’ voices are heard. Surveys on patient safety culture. This family of surveys asks healthcare providers and staff about the extent to which their organisational culture supports patient safety. Each survey is designed to assess patient safety culture in a specific setting. Diagnostic Centers of Excellence. These grants establishing 10 centres of excellence are aimed at developing systems, measures, and new technology solutions to improve diagnostic safety and quality.
  12. Content Article
    The Leapfrog Group is a non-profit watchdog organisation that serves as a voice for healthcare consumers in the US, using their collective influence to foster positive change in healthcare. It provides patient safety ratings for hospitals, grading them from A to E. This article in Becker's Hospital Review highlights the patient safety priorities for 2023 of eleven US hospitals that have consistently been awarded 'A' grades by Leapfrog. Key themes include a focus on reducing healthcare associated infections, increasing psychological safety for staff and improving communication between staff and patients.
  13. News Article
    Prostate cancer patients across the UK face a “postcode lottery” of care, a charity has warned, with men in Scotland almost three times more likely to be diagnosed at a late stage compared with men in London. Prostate Cancer UK said the proportion diagnosed when the disease may be too advanced to treat varied hugely depending on where patients lived. Health leaders called the findings “shocking”. In Scotland, more than a third (35%) of men are only diagnosed when the disease is classed as stage 4, meaning the cancer has spread to another part of the body – known as metastatic cancer. In London, the figure is 12.5%. Chiara De Biase, director of support and influencing at Prostate Cancer UK, said, "We can’t say for sure what’s behind this gap in diagnosis, but it’s clear that men are more likely to be diagnosed at an earlier stage in areas with higher rates of PSA blood testing. That means the key way to tackle this is by raising awareness – especially in places like Scotland which are worst-affected." Read full story Source: The Guardian, 12 January 2023
  14. Content Article
    In November 2021, 15-year old Alice Tapper nearly died due to a missed diagnoses of a perforated appendix. In this opinion piece, Alice shares her experience of being admitted to hospital with intense abdominal pain and other serious symptoms. In spite of her parents' requests for imaging to rule out appendicitis, doctors diagnosed that Alice had a viral infection and refused to prescribe antibiotics. Alice's condition severely deteriorated, leading her father to call the hospital and beg a gastroenterologist for further investigation. Fortunately, the hospital granted his request and after an x-ray and ultrasound, Alice was found to have a perforated appendix. She was going into hypovolemic shock, when severe blood or other fluid loss makes the heart unable to pump enough blood to the body. Thankfully, emergency surgery and antibiotics saved Alice's life, but she reflects on the fact that without her father's intervention, she would probably have died. She describes how her doctors failed to take the concerns she and her parents repeatedly expressed seriously, and that this lack of responsiveness could have been fatal. She highlights research that shows that appendicitis is missed in up to 15% of paediatric patients, and that missed diagnosis is most common in children under five, and is more common in girls than boys.
  15. News Article
    A senior doctor has told Scottish ministers to drop “patient-blaming language” over “unnecessary attendances” at emergency departments. Lailah Peel, the deputy chairwoman of the British Medical Association in Scotland, said the phrase suggested that patients were responsible for the problems and showed a misunderstanding of the issues. Patients have waited 30 hours for beds in overcrowded A&E units while ambulances have queued outside hospitals waiting to hand over patients to overstretched staff. Sturgeon, announcing measures to ease the strain, said: “To reduce the pressures in hospital and the knock-on impacts at the front door we need to do more firstly to avoid unnecessary attendances at hospital and second to speed up the discharge of patients from hospital.” Read full story (paywalled) Source: The Times, 12 January 2023
  16. News Article
    Some hospitals in Scotland have been told to postpone surgeries to ‘decongest’ the system as the crisis in the health service deepens. A group of NHS hospitals has stopped routine surgery for three weeks in an unprecedented step, as pressures mount on the health service. Health bosses at the NHS Ayrshire & Arran trust warned of “extremely high demand” across the system, as they also asked GPs to see only urgent cases. Rishi Sunak has repeatedly urged trusts to avoid cancelling elective surgery, urging hospitals not to repeat the errors made in the pandemic, which resulted in record backlogs. Clare Burden, the chief executive of NHS Ayrshire & Arran, said the cancellations were necessary "due to a combination of staff absence across the system, high bed occupancy levels in our acute and community hospitals, high levels of flu and Covid in our community, some delayed transfers of care, and high volumes of frail patients whose recovery includes complex care.” Read full story (paywalled) Source: The Telegraph, 11 January 2023
  17. Content Article
    The National Guardian's Office and the role of the Freedom to Speak Up Guardian were created in response to recommendations made in Sir Robert Francis QC’s 2015 report The Freedom to Speak Up. The office leads, trains and supports a network of Freedom to Speak Up Guardians in England and conducts speaking up reviews to identify learning and support improvement of the speaking up culture of the healthcare sector. This annual report shares intelligence and learning collated by the National Guardian’s Office, including data about the cases Freedom to Speak Up Guardians receive. Over 20,000 speaking up cases were brought last year, meaning cases remain at the record level set in 2020/21. The report also features case studies from different healthcare providers across England, sharing the experiences of people who have spoken up about a wide range of issues, and demonstrating the ways in which organisations have improved staff confidence in being able to speak up.
  18. News Article
    Trusts have been told today by NHS England that they must book appointments by the end of this month for all patients who have been waiting longer than 78 weeks. A letter from NHS England sent to trust leaders set out the new orders and represents system leaders’ attempt to ramp up progress on this cohort of patients, which the NHS and government elective recovery plan commits to eliminating by March. The appointments must be issued this month, and be dated before the end of March, for these pathways, of which about 48,000 are recorded nationally. The letter also warns trusts that, while NHSE will accept some inpatient cancellations are unavoidable, cancelling outpatient appointments — even during strike action — is viewed as less acceptable. Read full story (paywalled) Source: HSJ, 12 January 2023
  19. Content Article
    In this blog, Jonathan Back, Intelligence Analyst at the Healthcare Safety Investigation Branch (HSIB), looks at the opportunities the healthcare system has to adopt proactive risk management to improve patient safety. He highlights that understanding the value of different perspectives may provide new opportunities for improvement if applied across the health and care system. He also outlines the role of the new integrated care boards (ICBs) in achieving this whole-system approach, which should include a clinical governance perspective, organisational and local system perspective and societal perspective.
  20. News Article
    Ambulance bosses have apologised to the family of a man who died after he had a heart attack but no ambulance came. Martin Clark, 68, started suffering with chest pains at his home in East Sussex on 18 November - before any strike action started in the NHS. His family rang three times for an ambulance and after waiting 45 minutes drove him in their car to hospital. When they arrived, the father of five went into cardiac arrest and, despite receiving medical attention, died. Dr Sonya Babu-Narayan of the British Heart Foundation (BHF), said cases such as the Clarks' were "incredibly distressing". "The difference between life and death can be a matter of minutes when someone is having a heart attack or stroke," she said. "Extreme delays to emergency heart and stroke care cannot become a new normal. Healthcare staff are doing all they can—but there aren't enough of them and many will be working in difficult conditions without fit-for-purpose facilities." Read full story Source: BBC News
  21. Content Article
    This guidance on implementing human factors in anaesthesia has been produced by the Difficult Airway Society and the Association of Anaesthetists. Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker wellbeing; implementing human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a ‘hierarchy of controls’ model and classified into design, barriers, mitigations and education and training strategies.
  22. News Article
    No new Ebola infections have been detected in Uganda for 42 days, and so on Wednesday, the World Health Organization and the Ugandan Ministry of Health officially declared that the country’s most recent outbreak of the deadly virus is at an end. Since the outbreak was officially recognised on September 20, 164 people have had confirmed or probable Ebola infections; there 55 deaths confirmed by lab testing, with another 22 deaths suspected of being caused by the virus. Those who have recovered from the virus will receive ongoing support and will be closely monitored to help scientists understand the long term impacts of the Sudan strain of the virus, for which there are currently no treatment or prevention options. The Ugandan government has also set a goal of finally identifying the animal reservoir for Ebola. Read full story Source: CNN, 11 January 2023
  23. News Article
    An inspection of a hospital has found all wards were understaffed, while ‘tearful [and] exhausted’ clinicians raised patient safety concerns to the Care Quality Commission (CQC). The CQC’s visit to Colchester hospital, run by East Suffolk and North East Essex Foundation Trust, also found patients going unfed because of low staffing ratios and patient confidentiality concerns. The concerns were raised in a letter sent by the CQC to the trust, which also runs Ipswich hospital, ahead of publication of an inspection report for older people’s medical services, which is due later this month. The CQC’s letter, published in board papers for a meeting on Thursday, said: “All wards’ actual staffing levels and skill mix meant staff were often overstretched. All staff we spoke with expressed concern about the impact on patient care and personal wellbeing. Some staff we spoke with were tearful, reported feeling exhausted and concerned that they were unable to care for patients well enough to keep them safe.” The letter also said significant positives were found. Inspectors “found staff to be welcoming, hardworking and supportive of each other… We found staff at all levels working together with the aim of putting the patients first and providing a safe and effective service”. Read full story (paywalled) Source: HSJ, 11 January 2023
  24. News Article
    The Care Quality Commission (CQC) has sounded the alarm over a “concerning decline” in women’s experiences with maternity services. Fewer women feel they always got the help they needed during labour and birth, many were disappointed at the amount of time their partners could stay with them after the delivery of their babies, and a significant number reported that they did not feel listened to when they raised concerns. The CQC said it has noticed a “deterioration” over the last five years in the ratings women gave their care. It came as a major new national poll showed a “statistically significant downward trend” on most measures examined to track maternity care across the country. In particular, concerns were raised about staff availability, confidence and trust, as well as kindness and understanding of staff. Ratings also tumbled for whether women felt they had been treated with dignity and respect, the amount of information provided to mothers, and their concerns about being listened to. Victoria Vallance, from the CQC, said: “These results show that far too many women feel their care could have been better. This reflects the increasing pressures on frontline staff as they continue in their efforts to provide high-quality maternity care with the resources available.” Read full story Source: The Guardian, 11 January 2023
  25. Content Article
    These practical guides from NHS England are suitable for those working at all levels in the health service, from ward to board. They provide information on how to make better use of data. Guides include: Making data count - getting started Making data count - strengthening your decisions
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