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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    In this article, Maryanne Demasi looks at the continued prescription of Makena, an injectable synthetic hormone approved by the US Food and Drug Administration (FDA) to women who are at high-risk of premature delivery. Makena claims to reduce the risk of pre-term birth and was approved in 2011 on an accelerated pathway by the FDA following an initial trial that showed positive outcomes. However, Demasi explains, the study has been discredited as flawed in its methods and findings, and a confirmatory trial conducted by the manufacturer showed that Makena does not actually prevent preterm birth. In spite of this, and in the face of known risks, Makena is still being prescribed to pregnant women as the manufacturer has refused to withdraw it from the market. She highlights the dangers of the FDA not taking stronger action against the manufacturer of Makena, by looking at the example of Diethylstilbestrol (DES), a synthetic hormone use by women from the 1930's to the 1970s to prevent miscarriages and premature births. DES was later found to cause cancers, immune and cardiovascular disorders and other abnormalities in pregnant women, their children and their grandchildren.
  2. News Article
    Most hospital patients and care home residents in England will no longer be tested for Covid unless they have symptoms, the government has said. From 31 August, NHS and social care staff will also not be offered lateral flow tests unless they fall sick. Free testing for the general public ended in April in England, but continued in some high-risk settings. Health Secretary Steve Barclay said: "This reflects the fact case rates have fallen and the risk of transmission has reduced, though we will continue to closely monitor the situation and work with sectors to resume testing should it be needed." Read full story Source: BBC News (25 August 2022)
  3. Content Article
    This is the witness statement submitted by the claimant at an employment tribunal between Dr Chris Day and Lewisham and Greenwich NHS Trust. Dr Day's claim is based on his belief that the actions of the Trust irreparably damaged his medical career and had a significant impact on his job security and other areas of life. The document contains Dr Day's statement about the following events: Misrepresenting the substance of the protected disclosures Misrepresenting formal investigation findings Cost threat detriments Events post-settlement Impact of the case on Dr Day and his family
  4. Content Article
    The Health and Care Act 2022 and reforms to the public health system have introduced a range of changes and some simplifications to the landscape of national bodies in the health and care system. This blog explains the core functions of the national bodies with the most significant role in setting policy for and shaping the operation of the health and care system. It also looks at how these organisations are held accountable for carrying out those functions and the extent to which central government can direct them.
  5. News Article
    Two new London hospitals will not open until 2027 at the earliest, the BBC has been told. In 2019, the government pledged to build a new hospital in Sutton and another at Whipps Cross in east London. The St Helier complex in Sutton in south London dates back to the 1930s and much of the Epsom site is about 40 years old. But Dr Ruth Charlton, chief medical officer at Epsom and St Helier Hospital, said: "Our working conditions... are not fit for 21st century healthcare. We really feel that our patients and or staff deserve facilities that would allow them to deliver the quality of healthcare that we all wish to receive." A Department of Health and Social Care spokesperson said: "We have committed to deliver 40 new hospitals by 2030, backed by an initial £3.7bn. We are working closely with all the schemes in the programme and providing funding to develop their plans - final funding allocations are only confirmed once business cases have been fully reviewed and agreed. By taking a more centralised approach, we will reduce the overall time taken to build the hospitals and provide better value for money for the taxpayer." Read full story Source: BBC News (25 August 2022)
  6. Content Article
    This document has been produced as part of a project to develop EU guidance for the safe management of hazardous medicinal products (HMPs) at work, including cytotoxins. The project involves the collection of information from key stakeholders across 27 European countries through direct requests, workshops and pilots. The document provides practical guidance on preventing and reducing occupational exposure to HMPs for employers, workers, occupational health and safety (OSH) services and experts, personal training managers and others concerned with advice on the safe management of HMPs at work. The project team is inviting feedback on the draft guidance by 19 September 2022. The guide primarily addresses the following problems: Lack of awareness of HMPs Lack of support tools Unclear definition of HMPs Deficiencies in the flow and/or transfer of information.
  7. Event
    To mark the annual World Patient Safety Day, three organisations - COHSASA of South Africa, AfiHQSA of Ghana and C-CARE (IHK) of Uganda - are collaborating to bring you the latest thinking across Africa regarding 'Medication without harm', the theme for WHO's Third Global Patient Safety Challenge. The Challenge aims to reduce the global burden of iatrogenic medication-related harm by 50% within five years. Join us to hear new ideas, visions and solutions to address medication-related adverse events which cause untold death and suffering around the world. Register for the meeting FINAL INVITE FOR WPSD WEBINAR.pdf
  8. News Article
    Senior leaders of an ambulance trust have been told their ‘extreme positivity’ has made them appear ‘out of touch’ as the Care Quality Commission downgraded the organisation’s rating to ‘inadequate’. The health watchdog has dropped the overall rating of South Central Ambulance Service Foundation Trust, as well as the provider’s ratings for safety, leadership and for its urgent and emergency care services, from “good” to “inadequate”. The CQC has served SCAS with a warning notice and has criticised the trust’s board for its “extreme positivity about its performance”, which “could feel dismissive of the reality to frontline staff.” The regulator also said it saw evidence “of executive leaders attempting to discredit people raising valid concerns” and was told that serious concerns including sexual harassment had been “brushed under the carpet”. The CQC, which published the report today, also said there was “no evidence” of action being considered by SCAS to manage risk for patients suffering long handover delays outside A&E departments, and that serious issues “had not been addressed internally”. Will Hancock, chief executive of SCAS, said the trust had an “extensive improvement plan” and is “committed to making things better”. Read full story (paywalled) Source: HSJ (25 August 2022)
  9. Content Article
    This webpage highlights press coverage of the Chris Day whistleblowing hearing which took place in June 2022. Dr Day's case originates in 2013, when he initially raised concerns about unsafe staffing levels at Woolwich Hospital ITU, run by Lewisham and Greenwich NHS Trust. Following this, senior management in the Trust made allegations about his conduct, he believes as a result of his whistleblowing action. As a result Health Education England (HEE) deleted Dr Day's training number, meaning he was unable to progress to become a consultant. Dr Day has been campaigning for a public hearing of the case since 2016, and believes HEE, Lewisham and Greenwich NHS Trust and other authorities have spent large amounts of money attempting to 'crush' his case and prevent it from being heard. The tribunal hearing finally took place in June 2022 and featured revelations about Trust staff deliberately deleting emails relevant to the case, partisan briefings made to senior NHS management about Dr Day and inaccurate press statements from the Trust.
  10. Content Article
    This is the report of an employment tribunal concerning claimant Terence Burke, who was employed as a caretaker for the charity Turning Point Scotland. The tribunal ruled that Mr Burke was a disabled person within the meaning of s6 of the Equality Act 2010, and therefore unfairly dismissed by Turning Point Scotland in August 2021. The tribunal found that Mr Burke was disabled as he was suffering from Long Covid. This is the first case of Long Covid being classed as a disability in an employment tribunal and the ruling is likely to have implications on future cases concerning employees with Long Covid.
  11. News Article
    At the beginning of this year, there was a thrum of excitement among global health experts: Eradication of polio, a centuries-old foe that has paralyzed legions of children around the globe, seemed tantalizingly close. But there were several ominous setbacks. Malawi in February announced its first case in 30 years, a 3-year-old girl who became paralyzed following infection with a virus that appeared to be from Pakistan. Pakistan itself went on to report 14 cases, eight of them in a single month this spring. In March, Israel reported its first case since 1988. Then, in June, British authorities declared an “incident of national concern” when they discovered the virus in sewage. By the time New York City detected the virus in wastewater last week, polio eradication seemed as elusive as ever. “It’s a poignant and stark reminder that polio-free countries are not really polio-risk free,” said Dr. Ananda Bandyopadhyay, deputy director for polio at the Bill & Melinda Gates Foundation, the largest supporter of polio eradication efforts. The virus is always “a plane ride away,” he added. Read full story (paywalled) Source: The New York Times (18 August 2022)
  12. Content Article
    A Treatment Escalation Plan (TEP) is a communication tool designed to improve quality of care in hospital, particularly if patients deteriorate. TEPs aim to reduce variation caused by discontinuity of care, avoid harms caused by inappropriate treatment and promote patients’ priorities and preferences. This article in the Journal of the Royal College of Physicians of Edinburgh examines the key components of a TEP, how and why TEPs should be implemented and the outcome-related evidence to support their use.
  13. News Article
    Hospital bosses have warned that they face “impossible choices” under Liz Truss’s plan to divert £10 billion a year from the NHS to social care. They say that her pledge to remove cash earmarked for the health service will “slam the brakes” on efforts to tackle record waiting lists, with patients bearing the brunt. An extra £36 billion has been ring-fenced for health and care spending over the next three years, of which less than £2 billion a year is due to go towards social care. Truss, the frontrunner in the Conservative leadership contest, has announced that as prime minister she will divert the entire amount to local authorities to pay for older people’s care. This would create a £10 billion shortfall in annual NHS spending, the equivalent of imposing a 7 per cent budget cut on the service. NHS bosses say that they would have no choice but to cut services as they face the worst winter crisis in living memory, forcing patients to wait longer for treatment. There are already 6.7 million people on waiting lists, while patients are dying because of a sharp increase in ambulance response times and accident and emergency waiting times are the worst on record. Truss told a Times Radio hustings: “I still would spend the money. I would just take it out of general taxation rather than raising national insurance. But I would spend that money in social care. Quite a lot has gone to the NHS. I would give it to local authorities.” Read full story (paywalled) Source: The Times (25 August 2022)
  14. News Article
    Nurses at 15 hospitals in the Twin Cities area (Minneapolis-St Paul) and Duluth, Minnesota, that are negotiating new union contracts with their respective hospitals have overwhelmingly voted to authorize a strike. A date for the work stoppage has not been set yet by the union, the Minnesota Nurses Association, which represents about 15,000 nurses who voted on the strike authorization, but a 10-day notice must be given ahead of any strike. If a strike is carried out, it would be one of the largest nurses’ strikes in US history. Jayme Wicklund, a registered nurse at the Children’s hospital in St Paul, Minnesota, and member of the negotiating committee, said, “We need more resources to take care of the patients. The hospitals are very focused on wages. We have to be comparable to other places. But that’s all that they focus on. Once you start talking about wages, they don’t want to talk about the other important issues around patient safety or actually, other ways to save money.” Read full story Source: The Guardian (23 August 2022)
  15. News Article
    Rishi Sunak has claimed that it was a mistake to “empower scientists” during the coronavirus pandemic and that his opposition to closing schools was met with silence during one meeting. The Conservative leadership candidate believes one of the major errors was allowing the Scientific Advisory Group for Emergencies (Sage) to have so much influence on decision making such as closing nurseries, schools and colleges in March 2020. Sunak also disclosed that he was banned from discussing the “trade-offs” of imposing coronavirus-related restrictions such as missed doctor’s appointments and NHS waiting list backlogs. In an interview with the Spectator to be published on Saturday, the former chancellor said: “We shouldn’t have empowered the scientists in the way we did. And you have to acknowledge trade-offs from the beginning. “If we’d done all of that, we could be in a very different place. We’d probably have made different decisions on things like schools.” Read full story Source: The Guardian (24 August 2022)
  16. News Article
    The NHS has been forced to publish hidden trolley waits data, after intervention by the UK Statistics Authority, The Independent has learned. In a letter to NHS Digital and NHS England in July, Ed Humpherson director general for regulation at UKSA asked the organisations to publish monthly data on patients whose total wait in A&E is longer than 12 hours, following an ongoing row with emergency care leaders. NHS England promised to publish this internal data but has yet to comply, and as a result it was referred to UKSA by the Royal College of Emergency Medicine over concerns that the public data is misleading. Dr Katherine Henderson, president of the Royal College of Emergency Medicine, told The Independent: “For some time, we have been calling for NHS England to publish the 12-hour data measured from time of arrival. This data will show the real scale and depth of the crisis that urgent and emergency care is facing. We believe that through transparency around the sheer number of patients facing 12-hour waits, we can drive political and health leaders into action. Read full story Source: The Independent (25 August 2022)
  17. News Article
    Firefighters have resorted to taking people to hospital in fire engines amid rocketing call-outs to medical emergencies. Fire and rescue services now respond to more “non-fire incidents” than fires in England, including cardiac arrests, suicide attempts and elderly people trapped in their homes after falls. Official statistics show that they attended more than 18,200 medical incidents in 2021-22, an increase of a third from the previous year, and that firefighters rather than ambulances were the “first responder” in almost half of those calls. Chris Lowther, who chairs the National Fire Chiefs’ Council’s operations committee, said the figures showed a “new reality” as firefighters step in to help struggling ambulance services. Read full story Source: The Independent (22 August 2022)
  18. News Article
    The mother of a seven-year-old girl who died at Perth Children's Hospital says she pleaded with staff to help her daughter but was not taken seriously. Aishwarya Aswath died in April last year after attending the Perth Children's Hospital (PCH) with a high temperature and cold hands. The Perth Coroner's Court on Wednesday heard a statement from Aishwarya's mother Prasitha Sasidharan, who described how she grew increasingly worried about her daughter while in the hospital waiting room. She approached staff five times while they were in the waiting room for almost two hours. "I feel like I was ignored and not taken seriously," she said. The court heard from both parents on Wednesday, the start of an eight-day inquest. After Aishwarya died her father wanted to hold her but was only allowed to do so for a brief time. In his statement, read to the court, he said there were "many missed opportunities to save her." Former PCH chief executive Aresh Anwar said the hospital was grappling with a rise in mental health presentations and a shortage of staff when Aishwarya died. Read full story Source: ABC News (24 August 2022)
  19. News Article
    Kath Sansom, a former journalist from Lynn is raising awareness about the potential risks associated with vaginal and rectal mesh surgery. Mesh implant surgery is used to treat prolapse and incontinence in women usually following childbirth, and some men have also had the procedure. But pain and complications after the implants have left hundreds of people in the UK in pain and so a campaign in 2015 was launched which has led to the Government announcing a suspension in the use of vaginal mesh. Kath initiated the Sling The Mesh campaign in 2015 following her own experience of mesh surgery. She said: "What is most important to women is financial redress. We are all innocent and have had our health and lives compromised. We shouldn't have to wait 40 years, as the victims of contaminated blood have. Some women are in wheelchairs and have lost pensions. I am not the woman that I was. It has taken a financial, physical and emotional toll." Read full story Source: Lynn News (24 August 2022)
  20. Content Article
    In this joint blog, Patient Safety Learning and Sling the Mesh highlight several issues with the specialist mesh centres set up by the NHS to provide treatment and surgery for women who have been harmed by mesh. We identify key patient safety issues and look at what needs to be done to ensure women receive timely, compassionate and appropriate treatment for complications they face as a result of mesh implants.
  21. News Article
    An acute trust has “palpable” cultural problems and staff “at all levels” have described an acceptance of “poor behaviours”, according to the Care Quality Commission. Some staff at Gloucestershire Hospitals Foundation Trust also reported a lack of trust in their senior managers and a “fear of speaking up”. The Care Quality Commission feedback was set out in a post-inspection letter to the trust’s acting chief executive Mark Pietroni last month following an inspection in June. The trust’s CEO Deborah Lee is currently off work as she recovers from a stroke. According to the CQC letter, published in the trust’s board papers ahead of a full inspection report which is due in the autumn, staff “articulated [to inspectors and said they] had observed rudeness and incivility throughout the organisation”. In a written statement, Professor Pietroni told HSJ he “fully recognised” the CQC’s feedback. Read full story (paywalled) Source: HSJ (24 August 2022)
  22. Content Article
    Compensation claims are a useful source of information on patient safety research. This study in The Journal of Patient Safety aimed to determine the main causes of surgical compensation claims and their financial impact on the health system. The authors analysed the frequency, causes, consequences, locations and surgical settings of compensation claims brought against the surgical area of the Murcia Health System between 2002 and 2018. The study found that the most frequent causes for claims were surgical error (42.4%) and treatment error (30.9%), and that the main surgical settings involved were orthopaedic surgery and traumatology (27.4%), gynaecology and obstetrics (25.7%) and “general surgery” (17.2%).
  23. Content Article
    In this opinion piece in The BMJ, consultant radiologist Giles Maskell examines changes to the ways in which medical imaging is used in the health service. He states that imaging used to be ordered, when necessary, at the end of a diagnostic process, whereas now many doctors are asking for scans before they will see a patient for the first time. The article highlights some of the implications of this shift in practice, including on screening service capacity and on the interpretation of test results.
  24. Content Article
    This leaflet produced by the Irish Health Services Executive (HSE) provides a central place for patients to record information about their medications. It acts as a reference point for patients to use when discussing their medications with a healthcare professional and includes a reminder of the Know, Check, Ask campaign, aimed at reducing medication errors in the community.
  25. Event
    until
    After two years with virtual workshops due to the Covid-19 pandemic, we are pleased to announce that the fifth International Workshop on Safety-II in Practice will be organised on site in Edinburgh, Scotland on September 7-9, 2022. The Workshop is organised by FRAMsynt. The workshop will begin with an optional half-day tutorial on Safety-II in Practice in the afternoon of September 7 (1330-1730 BST), and continue with two days of meetings and discussions from September 8 (0830-1700 BST) to September 9 (0830-1500 BST). There will be a walking tour of Edinburgh old town (hosted by Steven Shorrock) and a dinner on the evening of September 8 for those who wish to join. Aim of the workshop The aim of the workshop is to share experiences from existing and/or planned applications of a Safety-II approach in various industries and practices. The workshop will give the participants an opportunity to present and discuss problems encountered and lessons learned – good as well as bad, practical as well as methodological. The workshop is a unique opportunity for safety professionals and researchers to interact with like-minded colleagues, to debate the strengths and weaknesses of a Safety-II approach, and to share ideas for further developments. The guiding principle for the workshop is “long discussions interrupted by short presentations”. In order to achieve this, the number of participants will be limited to 60 – first come, first served. Participation The workshop is open to everyone regardless of their level of experience with Safety-II. It will address the use of Safety-II in a variety of fields and for purposes ranging from investigations, performance analyses, organisational management and development, individual and organisational learning, and resilience. The workshop will provide a unique opportunity to: Discuss and exchange experiences on how a Safety-II approach can be used to analyse and manage complex socio-technical systems. Receive feedback on and support for your own Safety-II projects and ideas. Learn about the latest developments and application areas of Safety-II. Develop a perspective on the long-term potential of a Safety-II approach. Discussion topics, presentations and papers You can contribute actively to the workshop by submitting proposals for: Topics or themes for panel discussions (preferably with a presentation or introduction, but open suggestions of themes are also welcome). Presentations of ongoing or already completed work in industry and/or academia. Ideas that you would like to get a second opinion on. Questions or issues that you have been wondering about and would like to hear more about. The relevance of a Safety-II perspective for individual and organisational learning. The strategic management of Safety-II: how to introduce changes to routines and daily practice. For each type of proposal, please provide a short abstract (about 100 – 200 words, but even less if need be) with a summary of what you would like to present or discuss and how you want to be involved. All proposals will be reviewed and comments to the submitters will be provided. Please submit your proposed contribution to: contact@humanisticsystems.com Register
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