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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. News Article
    Up to 100 nurses are to be recruited from Nepal to work in the NHS, despite global restrictions on employing health workers because of staff shortages in the country. The Department of Health and Social Care (DHSC) and the Government of Nepal have signed a new government-to-government agreement regarding the recruitment of Nepali health professionals to the UK. The move comes after the new health and social care secretary Steve Barclay announced plans to “significantly increase” overseas recruitment of health workers to help mitigate staff shortages in the UK. A 15-month pilot phase will initially see up to 100 nurses recruited from Nepal to work at Hampshire Hospitals NHS Foundation Trust. Read full story Source: Nursing Times (23 August 2022)
  2. News Article
    Patients may come to harm as a result of NHS 111 chaos, experts claimed on Tuesday as patients were advised to avoid the service this weekend. The helpline for urgent medical advice was targeted by cyberhackers earlier this month, leaving staff working on pen and paper. The Adastra computer software, used by 85 per cent of 111 services, was taken offline after the attack leaving call handlers unable to book out-of-hours urgent appointments and fulfil emergency prescriptions. But almost three weeks on, most staff are still operating without the system, leaving GPs unable to see patients’ medical records during urgent consultations or automatically forward prescriptions to pharmacies. The NHS has told hospitals to prepare public awareness campaigns to “minimise” pressures on urgent and emergency care services this winter. Some hospitals have already issued messaging urging patients not to turn up at accident and emergency (A&E), unless they are facing a “serious emergency.” Helen Hughes, chief executive of the charity Patient Safety Learning, said the continuing chaos raises “serious patient safety concerns” and will “inevitably result in avoidable harm”. Telling patients not to go to A&E “unless it is absolutely necessary” is only possible if GPs and NHS 111 “have the capacity and the resources to meet the demands that this places on them”, Ms Hughes said. “Significant delays in receiving a response are potentially missed opportunities for patients to receive timely medical advice and treatment that may prevent future harm,” she added. “Delays in receiving timely care and treatment will inevitably result in avoidable harm to patients.” Read full story (paywalled) Source: The Telegraph (23 August 2022)
  3. Content Article
    In partnership with the Healthcare Safety Investigation Branch (HSIB) and Learn Together, NHS England has published its Guide to engaging and involving patients, families and staff following a patient safety incident alongside the Patient Safety Incident Response Framework (PSIRF). This guide sets out expectations for how those affected by an incident should be treated with compassion and involved in any investigation process. In this podcast, the speakers introduce the guide, discuss how it was developed, and talk about future plans in the area of work. Speakers: Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England National Patient Safety Team Lauren Mosley, Head of Patient Safety Implementation, NHS England National Patient Safety Team Lou Pye, Head of Family Engagement, HSIB Jane O’Hara, Learn Together research team, Professor of Healthcare Quality and Safety, University of Leeds and Deputy Director of the Yorkshire Quality and Safety Research Group.
  4. News Article
    Liz Truss has pledged to halt the exodus of doctors from the NHS to tackle the Covid backlog and surging waiting lists. The frontrunner in the Conservative leadership race is planning to unveil a series of radical reforms that will stop doctors from retiring early and entice retirees to return. One in 10 consultants and GPs is expected to retire in the next 18 months because of pension rules that mean they are "paying to work". A source close to her said she would deal with it by “cutting red tape and dealing with issues in the pension and tax system that currently act as barriers for people wanting to return”. It comes amid concerns that the NHS backlog after lockdown is causing more than 1,000 excess deaths per week - more than the figure now killed each week by coronavirus. A source close to Liz Truss also said: “The Covid pandemic put unprecedented strain on our NHS, and the resulting backlog is seeing people struggling to get appointments and treatments. We must act to tackle it, and we will. We will make it easier for doctors and nurses who have recently left or are planning to leave the NHS but want to return or stay to do so.” Read full story (paywalled) Source: The Telegraph (20 August 2022)
  5. News Article
    An LMC has created template letters to help practices reject secondary care workload dumping, including rejected referrals and requests to complete work on behalf of hospital trusts. Cambridge LMC said it developed the tools amid a growing ‘tsunami’ of secondary care workload transfer into general practices. One template letter tackles the rejection of a referral ‘on the basis that a proforma was not enclosed or completed in full’. It points out that the GMC requires GPs to refer when they ‘believe it is necessary to do so’ and that their ‘contractual obligations make no mention of a requirement to complete a proforma’. Cambridgeshire LMC chief executive Dr Katie Bramall-Stainer told Pulse that ‘we need the temperature to rise on the understanding around pressures across general practice’. Read full story For more information on the issues raised, read a blog by Patient Safety Learning about the patient safety risks of rejected outpatient referrals. Source: Pulse (19 August 2022)
  6. News Article
    An immunologist has warned the new strain of Covid-19 could be causing different symptoms – including one that emerges during the night. Omicron BA.5 is a highly-contagious subvariant prompting concern as it contributes to a fresh wave of infections across the globe, including the UK. Scientists have been finding differences with previous strains, including the ability to reinfect people within weeks of having Covid. “One extra symptom from BA.5 I saw this morning is night sweats,” Professor Luke O’Neill from Trinity College Dublin told an Irish radio station in mid-July. Read full story Source: The Independent (24 August 2022)
  7. Content Article
    Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in healthcare systems across the world. In recognition of this, in 2017 the World Health Organization (WHO) launched the Third WHO Global Patient Safety Challenge: Medication Without Harm, aimed at improving medication safety. This article provides information and resources related to the Challenge.
  8. News Article
    Nearly 700 doctors are likely to leave the Welsh NHS as a result of a recent 4.5% pay rise, the British Medical Association has warned. The warning follows a survey by BMA Cymru, in which more than half of the 1,397 respondents said they could leave and most felt morale had dropped. The below-inflation pay rise will apply to consultants, junior doctors and GPs. The Welsh government said it accepted the NHS pay review body's advice and was limited on how far it could go. Dr Iona Collins, chairwoman of the BMA's Welsh Council, said the findings resonated with what she was hearing from colleagues across Wales. "Doctors' take-home pay has reduced over several years, making the NHS an increasingly unattractive employer," said Dr Collins. Read full story Source: BBC News (23 August 2022)
  9. Content Article
    In this blog for The King's Fund, Richard Murray examines the issues that are pushing the NHS into crisis and causing the lowest levels of public satisfaction since the 1990s. The primary cause of this emergency is the workforce crisis, an existing trend that has been accelerated by the Covid-19 pandemic. He examines the approaches that have been taken to similar crises in the past, and highlights the importance of the workforce plan that is due to be released by NHS England and Health Education England towards the end of the year.
  10. Content Article
    This statement from Chair Peter Wyman addresses allegations of bullying and racism within NHS Blood and Transplant as reported in The Times on 21 August 2022. In the statement, Peter Wyman says, "I cannot overstate the importance we place in ensuring we have a strong, positive and inclusive culture so we can serve the public and patients who need us.  “Issues of racism and bullying came to light in parts of our organisation two years ago after an in-depth staff listening exercise. We’ve moved on a lot in the past two years. Our actions have included providing a safe way for staff to raise and discuss issues by appointing a Freedom to Speak Up Guardian, improving recruitment processes to be more inclusive, matured how we manage conflict and grievances and refreshing our code of conduct so we all know the behaviours that are expected of us. We continue to measure progress through ongoing staff engagement.   “We are making progress but like every good organisation we should always be challenging ourselves to do even better. In particular, I want to ensure we have a culture that enables each of us to be our best, that encourages everyone to speak up without fear or favour if they see something wrong or something which might be done better. I want a culture where everyone is valued for who they are and what they contribute. "There can be no place for any form of discrimination, bullying or harassment.”
  11. Content Article
    This recording is part of a series of webinars by the Patient Academy for Innovation and Research (PAIR Academy), The International Alliance of Patients’ Organizations (IAPO) and Dakshama Health, to introduce the Strategic Framework of the World Health Organization's Global Patient Safety Challenge - Medication Without Harm. The theme of this sixth webinar is "Medication Safety in Polypharmacy and Transitions of Care."
  12. 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. Soojin talks to us about how her personal experience of harm motivated her to work in healthcare and campaign for patient safety, the power of collaboration in improving healthcare safety and how healthcare workers can take steps to improve their own patient interactions.
  13. Content Article
    The General Medical Council (GMC) is the UK's statutory body responsible for taking action to prevent a doctor from putting the safety and confidence of patients at risk. In this blog for The Spectator, doctor Max Pemberton argues that the GMC has lost the trust of doctors by bringing a series of inappropriate cases, resulting in the British Medical Association (BMA) calling for an overhaul of how the GMC is run. He describes some recent investigations as being about 'petty' issues and highlights the significant impact being under investigation can have on doctors' mental health.
  14. News Article
    Some of the country’s leading acute hospitals are not meeting a key NHS standard for mental health support in emergency departments, HSJ research suggests, with some regions faring better than others. Latest official estimates indicate that more than a third of EDs (36 per cent) are not yet meeting ‘core 24’ standards for psychiatric liaison – which requires a minimum of 1.5 full-time equivalent consultants and 11 mental health practitioners. The long-term plan target is for 70 per cent of acute trust emergency departments to have the optimum ‘core 24’ standard service by 2023-24. The NHS appears to be on track to hit this, with significant progress made, despite the pandemic. Annabel Price, chair of the Royal College of Psychiatrists’ liaison faculty, said tackling the workforce crisis with a fully funded plan would “prove instrumental in boosting recruitment across all acute trusts”. Read full story (paywalled) Source: HSJ, 23 August 2022
  15. Content Article
    Communication is extremely important to ensure safe and effective clinical practice. This systematic literature review of observational studies addressing communication in the operating theatre aimed to gain an understanding of actual communication practices, rather than what was reported through recollections and interviews. In all of the studies reviewed, communication was found to affect operating theatre practices. Further detailed observational research is needed to gain a better understanding of how to improve the working environment and patient safety in theatre.
  16. Content Article
    Poor communication among healthcare professionals contributes to widespread barriers to patient safety. The word “communication” means to share or make common. In research literature, two communication paradigms dominate: communication as a transactional process responsible for information exchange communication as a transformational process responsible for causing change. Implementation science has focused on information exchange attributes while largely ignoring transformational attributes of communication. This article in the journal Implementation Science debates the merits of encompassing both approaches.
  17. Content Article
    Hip fracture is a serious, life-changing injury that can affect older people, and is the most common reason for them to need emergency anaesthesia and surgery. The Physiotherapy Hip Fracture Sprint Audit (PHFSA) was the biggest ever audit of UK physiotherapy, and has implications for physiotherapists working in many settings.
  18. Content Article
    This report by the consultancy firm Deloitte looks at patient safety across biopharmaceutical (biopharma) value chains, arguing that change is needed to make medications safer for patients and add value to pharmaceutical products. The authors highlight that there is currently great potential for strategies to increase safety, improve equity and enhance patient engagement and experience. Advances in artificial intelligence (AI) technologies and data analytics, combined with increased incidence of adverse event reports (AERs) and increasing expectation of more personalised, preventative, predictive and participatory (4P) medicine, present an opportunity to improve pharmacovigilance.
  19. Content Article
    This blog on the NHS England website looks at how Written Medicine, a service that provides bilingual medication information, is helping to reduce healthcare inequalities and medical errors in London. Written Medicine’s software allows pharmacies and hospitals to translate and print medication information, instructions and warnings. Drawn from a dataset of 3,500 phrases, printed labels are available in fifteen different languages. The bilingual labels help patients take ownership of their treatment, giving them a better understanding of how to take their prescribed medication. The solution is helping to reduce errors, improve medication adherence and enhance patient safety and experience. The blog also looks at the experience of London North West University Healthcare NHS Trust (LNWH) using Written Medicine. A 2019 audit showed that the service was valued by patients and highly successful in increasing medication adherence through empowering patients.
  20. Content Article
    This document from the Department of Health and Social Care (DHSC) contains guidance for integrated care partnerships on the preparation of integrated care strategies. It contains an introduction, two sections of statutory guidance on the preparation of the integrated care strategy including involvement and content, and a section of non-statutory guidance relating to the publication and review of the integrated care strategy. It also includes case studies that demonstrate some of the innovative approaches taking place throughout England.
  21. Content Article
    These slides provide the outline of a tutorial about the Causal Analysis using System Theory (CAST) and System-Theoretic Accident Model and Processes (STAMP) approaches to accident analysis, delivered at the Second STAMP Conference in 2013. The presentation slides cover: Model and method: Why STAMP and CAST? Why do accident analysis? Goals for an accident analysis technique Overcoming hindsight bias CAST worked example of emergency plane landing
  22. Content Article
    This article by Penelope Hawe from the Menzies Center for Health Policy at the University of Sydney, looks at complexity and how it increases the unpredictability of interventions in systems. She argues that new metaphors and terminology are needed to capture the recognition that knowledge generation comes from the hands of practitioners as much as it comes from intervention researchers.
  23. Content Article
    These Quality Standards have been developed by the Resuscitation Council UK. They enable healthcare organisations provide a high-quality resuscitation service, with guidance tailored for different settings including acute care, primary care, dental care, mental health units, community hospitals and in the community.
  24. Content Article
    In this blog, Grace Annan-Callcott, Programme Adviser at the Understanding Patient Data programme (UPD) outlines the findings of a new report on the impact of including information about patient data in health charities' guidance. The report investigates whether adding small explanations about the role of patient data in developing health guidance affects people’s: perception of the information or advice general awareness or understanding of how patient data can be used. Working with a group of charities including Asthma + Lung UK, Best Beginnings, Cystic Fibrosis Trust, MS Trust, Stroke Association, National Autistic Society, British Heart Foundation and the Patient Information Forum (PIF), UPD set up a community of practice to research the impact of patient data in health guidance.
  25. Content Article
    In this blog, Charlotte Clayton, midwife and clinical advisor at the Organisation for the Review of Care and Health Apps (ORCHA), explores how providing the right training and support for maternity staff is key to seeing the benefits tech can bring to quality of care and workload.
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