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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. 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. Mark talks to us about his role as a National Patient Safety Partner (PSP). He explains the important role that PSPs play at national, regional and local levels of the healthcare system and identifies key opportunities and challenges they face in bringing the voice of patients and families at a strategic level. He also highlights the challenge of implementing the Patient Safety Incident Response Framework (PSIRF) across a diverse range of providers and the complexities arising where PSIRF interfaces with systems and processes outside of the NHS.
  2. Content Article
    This standard, which complements existing health and safety legislation, has been developed by NHS England. NHS employers have a general duty of care to protect staff from threats and violence at work, and the standard delivers a risk-based framework that supports a safe and secure working environment for NHS staff, safeguarding them against abuse, aggression and violence. It employs the Plan, Do Check, Act (PDCA) approach, an iterative four-step management method to validate, control and achieve continuous improvement of processes. It was developed in partnership with the Social Partnership Forum and its subgroups, including trade unions and the Workforce Issues and Violence Reduction Groups.
  3. Content Article
    The use of restrictive interventions, such as mechanical restraints, has been a common practice in behavioural health settings since the field’s early infancy. The use of restraints has a harmful impact on both patients and providers alike, working against the therapeutic treatment environment aimed to support the healing journey. In this quality improvement project, the use of mechanical restraints was fully eliminated from a 252-bed inpatient setting in the US. This was achieved using a strategy of leadership, workplace development and data, and performance was sustained over the following year.
  4. Content Article
    This study in Surgery aimed to assess the impact of presenting the STOPS framework (stop, talk to your team, obtain help, plan, succeed) on how surgeons cope in the operating room. It also looked at the related outcome of burnout and examined sex differences. The results suggest that there is evidence of efficacy in the STOPS framework—female surgeons who were presented this material reported higher levels of coping in the operating room compared to those who did not receive the framework. In addition, an increase in coping ability was associated with reduced levels of burnout for both genders.
  5. Content Article
    This study in Surgery aimed to investigate the accuracy of ChatGPT-4’s surgical decision-making compared with general surgery residents and attending surgeons. Five clinical scenarios were created from actual patient data based on common general surgery diagnoses. Scripts were developed to sequentially provide clinical information and ask decision-making questions. Responses to the prompts were scored based on a standardised rubric for a total of 50 points. Each clinical scenario was run through Chat GPT-4 and sent electronically to all general surgery residents and attendings at a single institution. Scores were compared using Wilcoxon rank sum tests. The results showed that, when faced with surgical patient scenarios, ChatGPT-4 performed superior to junior residents and equivalent to senior residents and attendings. The authors argue that large language models, such as ChatGPT, may have the potential to be an educational resource for junior residents to develop surgical decision-making skills.
  6. Community Post
    Hi @DKJoker84 You can email enquiries@ukcvfamily.org if you are interested in joining UKCVFamily's support forum for people who have experienced vaccine injury. They may be able to offer some signposting to research regarding your symptoms and services that can offer further support.
  7. Content Article
    This paper was presented to the NHS England board at its public session on 16 May 2024. It discusses the effect the pandemic has had on NHS productivity with details of NHS England’s estimates for the drivers of the loss of productivity observed. It also discusses the emerging plan to improve productivity in the coming years.
  8. Content Article
    These action cards developed by Mark Rigby, Head of Theatre Services at Warrington and Halton Teaching Hospitals NHS Foundation Trust, contain a checklist of actions to be taken in the event of: incorrect swab count incorrect instrument count incorrect missing sutures or small metal items count
  9. Content Article
    This audit tool developed by Mark Rigby, Head of Theatre Services at Warrington and Halton Teaching Hospitals NHS Foundation Trust, is designed to assess theatre compliance with the five steps to safer surgery, which includes the World Health Organization (WHO) Surgical Safety Checklist. The checks included in the five steps are designed to reduce the number of errors and complications resulting from surgical procedures by improving team communication and by verifying and checking essential care interventions. The tool features a monthly observation audit and documentation audit and presents recorded data in a results tab which tracks progress by month, providing more timely data locally than the clinical scorecard.
  10. Content Article
    In Birmingham, eight out of 10 Somali children live in ‘poor’ households with low levels of economic activity and high rates of mental health issues, such as PTSD. In the UK, six in 10 (59%) people in the Somali community live in overcrowded accommodation, compared to fewer than one in 10 (8%) of the overall population. Meanwhile, studies show that many Somali people find it difficult to access health and social care services, due to language and socio-economic barriers. Suad Duale is a community activist, clinician, mother and researcher who grew up as a Somali refugee in Birmingham. In this blog for The King's Fund, she describes how unfair treatment of the Somali community leads to a collective lack of trust in professionals, particularly in the health system. She describes the issues contributing to the disparities faced by the community, including a lack of people from the Somali community in leadership roles who are able to advocate for the needs of the community. She describes the work of Dream Chaser Youth Club in Birmingham, where she volunteers by acting as a link to help people from the Somali community connect with health and care services.
  11. Content Article
    This article by Saoirse Mallorie, Senior Policy Analyst at The King's Fund, looks at the detail behind the results of the 2023 NHS Staff Survey. She highlights that although it looks as though there has been improvement in some areas, staff satisfaction is not where it should be. The article also looks at variation between staff groups in terms of work-related stress, autonomy, belonging and workload, representing these differences visually in graphical form.
  12. Content Article
    Medicines waste is a significant problem in the NHS, with an estimated £300m wasted annually on unused or partially used medicines. In hospitals, this waste is added to when patients do not take their medicines home or when their medicines are not transferred with them as they change wards. In this blog for The Pharmaceutical Journal, Claire Williams, deputy clinical pharmacy manager at Hampshire Hospitals NHS Foundation Trust describes how her Trust reduced its medicines waste by moving patients’ medication with them and returning unused medication to the pharmacy in a timely manner. The Trust was participating in the Centre for Sustainable Healthcare ‘Green Team’ competition, and Claire and her colleagues saw it as an opportunity to showcase the impact that pharmacy can have in supporting the green agenda. This article is free to read but you will need to sign up for a Pharmaceutical Journal account to access it.
  13. Content Article
    This report commissioned by the US Agency for Healthcare Research and Quality aims to identify major themes related to the current state of diagnostic safety and highlight key gaps in knowledge. Through a rapid narrative review methodology to evaluate multiple resources in the literature and interviews with experts, it presents several findings that have implications for future resource investments to reduce harm from diagnostic errors. The report looks at the following key themes: Incidence and Contributing Factors Measurement: Data and Methods Cognitive Processes Culture, Workflow, and Work System Issues Disparities Health Information Technology Patients and Families Testing Interventions Implementation
  14. Content Article
    Large language models (LLMs) are a form of artificial intelligence that can generate human-like text and functions as a form of an input–output machine. They bring great potential to help the healthcare industry centre care around patients’ needs by improving communication, access and engagement. However, LLMs also present significant challenges associated with privacy and bias that also must be considered. This blog looks at three major patient-care advantages of LLMs, as well as the potential risks associated with using them in healthcare.
  15. Content Article
    FebriDx® is a single-use, analyser-free, point-of-care test with markers for bacterial and viral infection, measured on a finger-prick blood sample. As part of a larger feasibility study, this study explored the views of healthcare professionals (HCPs) and patients on the use of FebriDx® to safely reduce antibiotic prescriptions for lower respiratory tract infections (LRTI) in primary care. The authors concluded that the tool was perceived as a useful in guiding antibiotic prescribing and supporting shared decision making. Initial practical problems with testing and communicating results are potential barriers to use. Training and practice on using the test and effective communication are likely to be important elements in ensuring patient understanding and satisfaction and successful adoption.
  16. News Article
    More than 30 of the most common antidepressants used in the UK are to be reviewed by the UK’s medicines regulator, as figures point to hundreds of deaths linked to suicide and self-harm among people prescribed these drugs. The medicines, which include Prozac and are prescribed to millions of patients, will all be looked at by the Medicines and Healthcare products Regulatory Agency (MHRA). It follows concerns raised by families in Britain over the adequacy of safety measures in place to protect those taking the drugs, such as warnings about potential side effects. The regulator will look into the effectiveness of the current warnings, according to a letter from mental health minister Maria Caulfield, which has been seen by The Independent. There has been a huge rise in the use of antidepressants in England, with 85 million prescriptions issued in 2022-23, up from 58 million in 2015-16, according to NHS figures. Nigel Crisp, a crossbench peer and chair of the Beyond Pills all-party parliamentary group, told The Independent: “Overprescribing of antidepressants has an enormous cost in terms of human suffering, because so many people become dependent and then struggle to get off them – and it wastes vital NHS resources.” The review comes as it emerged that: More than 515 death alerts linked to these drugs, involving suicidal ideation and self-harm, have been made to the MHRA since the year 2000 (these alerts don’t directly confirm the cause of a person’s death) Some antidepressants have been given to children as young as four, and the total cost of the medication to the NHS in 2022-23 was more than £231m Read full story Source: The Independent, 11 May 2024
  17. News Article
    Giving teenagers the HPV vaccine is cutting cases of cervical cancer by 90%, figures for England show. Scientists say it works so well that this type of cancer could be eradicated in the near future. The study shows the vaccine is most effective when offered to Year 8 students - those aged 12 to 13. The vaccine also provides protection against genital warts by preventing human papillomavirus (HPV) infections. The study, funded by Cancer Research UK and led by experts at Queen Mary University of London, shows the HPV vaccine combined with cervical screening can dramatically reduce cervical cancer incidence to the point where almost no-one develops it. More cases were prevented in the most deprived socio-economic groups in society - those often hit hardest by the disease. Prof Peter Sasieni, lead author of the work that is published in the British Medical Journal,, external said: "Our research highlights the power of HPV vaccination to benefit people across all social groups. Historically, cervical cancer has had greater health inequalities than almost any other cancer and there was concern that HPV vaccination may not reach those at greatest risk. This study captures the huge success of the school-based vaccination programme in helping to close these gaps and reach people from even the most deprived communities." Read full story Source: BBC News, 16 May 2024
  18. Content Article
    This BMJ long-read article argues that health is going in the wrong direction in the UK, and reversing the trend requires political and societal commitment to deal with the underlying causes. It proposes evidence-based solutions to the worsening health and widening inequalities in the UK through action on the social determinants of health.
  19. Event
    until
    Telemetry monitors are patient-worn devices that allow the patient's heart rate, heart rhythm, and other physiologic conditions to be assessed without restricting the patient to a bed. These devices allow cardiac patients to move around the facility while still being monitored. Monitors are designed to transmit an alarm signal to nursing staff if the patient develops a concerning heart rhythm or other condition that requires attention. The safety and effectiveness of a telemetry monitoring program depends heavily on the organization's alarm management strategy. Any failure to recognize or delay in responding to a potentially life-threatening change in the patient's condition could lead to severe harm. As with any physiologic monitoring system, healthcare organizations must scrutinize all aspects of how telemetry alarms are initiated, how they are communicated, and how staff respond. The use of inappropriate alarm settings or notification processes can prevent staff from learning about a change in the patient's condition or may lead to frequent false alarms or nuisance alarms that overwhelm, distract, or desensitize staff—a phenomenon known as alarm fatigue. Either situation can result in valid alarm conditions being missed by staff, and thus a patient's deterioration going unnoticed. Improvements in the way that telemetry systems are implemented and managed can help combat alarm fatigue and reduce the risk of alarm-related adverse events. During this lab webcast, we will discuss: Alarm fatigue: what it is, why it is a concern, and how telemetry implementation decisions can contribute to this hazard Criteria for selecting patients for telemetry monitoring Policies and procedures for setting and disabling alarms Alarm escalation processes and secondary alarm notification systems Strategies to optimize the monitor watching function Register for the webcast The webcast will take place at 12:00 ET, 17:00 BST
  20. Content Article
    The Safe Learning Environment Charter supports the development of positive safety cultures and continuous learning across all learning environments in the NHS. It is underpinned by principles of equality, diversity and inclusion. It has been developed by over 2482 learners, educators and key stakeholders in health education. The Charter was created by NHS England in response to healthcare learners’ feedback on their clinical experiences in maternity services, set out in the Kirkup (2015 and 2022) and Ockenden (2020 and 2022) reports. The Charter is designed for learners and those responsible for supporting placement learning across all learning environments and all professions within them. It is aligned to the NHS People Promise in recognition that learners are vital to the workforce and are included in the promises NHS staff and leaders must all make to each other, to improve everyone’s experience of working in the NHS. The Charter sets out the supportive learning environment required to allow learners to become well-rounded professionals with the right skills and knowledge to provide safe and compassionate care of the highest quality.
  21. News Article
    More than 50 NHS whistleblowers claim to have lost their jobs—with some driven to the brink of suicide—after standing up to protect patients’ lives as bosses bury their concerns. The group of doctors and nurses said that they had been targeted after raising concerns about more than 170 patient deaths and nearly 700 cases of poor care. One consultant said that it was the “biggest scandal within our country” and claimed the true number of avoidable deaths was “astronomical”. Instead of addressing the problems, the whistleblowers claim that NHS bosses are spending millions of pounds of taxpayers’ money on hiring law firms and private investigators to investigate them instead. Last year Rob Behrens, the health ombudsman, warned The Times Health Commission that patient safety was at risk due to “toxic” and hierarchical behaviour among NHS doctors. Professor Phil Banfield, the chairman of the council of the British Medical Association, which represents doctors, wrote in The Daily Telegraph that whistleblowing “is not welcomed by NHS management… NHS trusts and senior managers are more concerned with protecting personal and organisational reputations than they are with protecting patients.” In one case, the NHS spent more than £4 million on legal action against a single whistleblower, which included £3.2 million in compensation. Among the clinicians interviewed, 40 said that their employer took “no positive action” to address patient safety concerns; 36 said that patients remained at risk at their place of work; 19 said that NHS trusts covered up the problems, and ten said that their employers had denied there was a problem. Whistleblowers’ representatives are urging the government to require independent medical assessments for claims and to ban the suspension or exclusion of doctors for speaking out about patient safety. Dr Naru Narayanan, president of the hospital doctors’ union, has called for an independent national whistleblowing body outside of the NHS to register protected disclosures and protect individuals against recriminations. The Times Health Commission recommended that a no-blame compensation scheme should be introduced for medical errors, with settlements determined according to need. Backed by Jeremy Hunt, the chancellor, the scheme would help end the deadly cycle of NHS scandals and cover-ups and ensure families receive timely support. Read full story (paywalled) Source: The Times, 15 May 2024
  22. News Article
    A trust is experiencing severe problems with its electronic patient record system two years after it was installed, HSJ research has revealed. A “preliminary review” into the Oracle Cerner electronic patient record – called Surrey Safe Care – at Ashford and St Peter’s Hospitals (ASPH) Foundation Trust in Surrey found the emergency department was still spending “significant time” using the system, an electronic bed board was not updated in real-time, and there were booking and workflow errors in clinics. The review, which was released to HSJ after a Freedom of Information Act request and carried out in recent months, found problems stemming from limited system training, configuration issues and insufficient technology available on wards and in clinics. The EPR went live in May 2022. The trust also had “insufficient analysts” to provide comprehensive management information. Also, performance, utilisation and management information were described as still being “under construction.” In a statement, ASPH said, “Annual reviews will be carried out to monitor the continual progress of this project. A new working group of clinical, operational, and digital staff will agree how we use existing resources to improve staff training, add extra functionality to the EPR, invest in appropriate technology and additional analysts.” Read full story (paywalled) Source: HSJ, 15 May 2024
  23. Content Article
    In this blog, Miqdad Asaria, Assistant Professor at the Department of Health Policy at LSE, argues that AI could lead to a paradigm-shift in healthcare systems likes the NHS. He outlines how AI could help personalise medical treatments, enhance research and development of new drugs and help with the administrative burden currently undermining the productivity and efficiency of healthcare providers.
  24. Content Article
    This is the second ‘saving babies’ lives’ progress report from the Joint Policy Unit. When the first report was published in May 2023, the Unit committed to reassessing progress each year. Through this process it aims to hold government and decisionmakers to account, helping to ensure that saving babies’ lives and tackling inequalities in pregnancy and baby loss are the political priorities they deserve to be. This years report highlights that maternity services need a much more transformative approach from government, that matches the scale and impact of the issue. Maternity services are not on course to meet government ambitions to reduce rates of stillbirth, neonatal death or preterm birth, and there continue to be stark and persistent inequalities in rates of pregnancy and baby loss by ethnicity and deprivation. View a summary version of the report
  25. News Article
    A mother of five died of endometrial cancer hours after being admitted to A&E following preventable delays in her diagnosis. An inquest was told that a private clinic identified the cancer by ultrasound but the report was never sent to her GP. Kerri Mothersole, 44, from Swale in Kent, had a complex medical history including decades of depression and chronic back pain. Her 21-year-old son, Jordan Dighton, said: “My mum should have been taken more seriously—if she were, maybe she’d still be alive.” In May 2020 Mothersole presented with symptoms of early menopause. Blood tests showed that she had low iron levels and her symptoms persisted. In March 2021 she told her GP at Green Porch Medical Centre that she had had vaginal bleeding for six weeks. She could not attend her ultrasound appointments because she was the family’s only driver, and was removed from the waiting list despite rescheduling two appointments. In June of that year her GP referred her for an NHS scan at HEM Clinical Ultrasound Service in Sittingbourne. A radiographer, who was new to the private clinic, found a suspected ovarian mass. However, the clinical lead deemed the scan results inaccurate so they were never returned to the GP. Instead Mothersole was asked to attend a second pelvic and abdominal scan. She was losing weight and in persistent pain. Despite her symptoms being gynaecological, she underwent what turned out to be a clear colonoscopy. According to the coroner, had the first scan report been seen this would have led to an urgent referral to gynaecology. Mothersole was eventually admitted to A&E, where she remained under the care of oncology until she was discharged home to the care of hospice nurses. Dighton told The Times, “The system was so siloed and her case was passed around from department to department. It’s only after her death that we’ve started to make sense of what pathways she should have been on.” Read full story (paywalled) Read the Prevention of Future Deaths Report for Kerri Mothersole Source: The Times, 15 May 2024
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