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Sam

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  1. Event
    This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. You’ll also be directed to specific activities designed to extend and consolidate your knowledge. Register
  2. Event
    This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. You’ll also be directed to specific activities designed to extend and consolidate your knowledge. Register
  3. News Article
    Staff fell asleep while on duty at a mental health trust, inspectors found. The Care Quality Commission (CQC) said it was "very disappointed" to find patient safety being affected by the same issues it had seen previously. It said on acute wards for adults of working age and psychiatric intensive care units, five patients described staff falling asleep at night. Despite CCTV being available, managers told the CQC they could not always immediately prove staff had been sleeping as accessing the pictures could take up to a fortnight. The CQC report added trust data from June to December 2022 recorded 20 incidents of staff falling asleep while on duty but no action was taken because the video evidence had not been viewed. Rob Assall, the CQC's director of operations in London and the East of England, said: "When we inspected the trust, we were very disappointed to find people's safety being affected by many of the same issues we told the trust about at previous inspections. "This is because leaders weren't always creating a culture of learning across all levels of the organisation, meaning they didn't ensure people's care was continuously improving or that they were learning from events to ensure they didn't happen again." Read full story Source: BBC News, 12 July 2023
  4. News Article
    A scheme in which ‘category 2’ 999 calls are validated by clinicians will be extended nationally after reducing journeys by 4%in a pilot, with no adverse incidents, NHS England has told HSJ. NHSE also confirmed that one ambulance trust in the scheme, the West Midlands, has begun delaying the dispatch of ambulances for some category 2 calls by up to 23 minutes so that the validation can take place. At three other trusts – London, South Western and the East Midlands – about 40% of category 2 calls receive clinical validation, but an ambulance is dispatched to them as soon it is available, as normal. Officials said they believe the demand benefit could be greater if ambulance trusts are able to devote more clinical capacity to the validation process. About 40% of category 2 calls are judged suitable for validation, but not all of them complete the process before an ambulance arrives. Read full story (paywalled) Source: HSJ, 11 July 2023
  5. Event
    This national conference looks at the practicalities of Serious Incident Investigation and Learning from Deaths in Mental Health Services and implementation of the New Patient Safety Incident Response Framework (PSIRF previously known as the Serious Incident Framework). The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-of-deaths-serious-incidents-in-mental-health-services or email kate@hc-uk.org.uk hub members receive 20% off. Email info@pslhub.org for discount code. Follow this conference on Twitter @HCUK_Clare #SIMental
  6. Event
    The Department of Health and Social Care announced on the 5th April 2023 that the implementation of the Liberty Protection Safeguards will be delayed until at least the next general election (anticipated to be in Autumn 2024). With the delay to the Liberty Protection Safeguards it is more important than ever to ensure the existing scheme of Deprivation of Liberty Safeguards (DoLS) works, that providers understand the application of Deprivation of Liberty Safeguards and interaction with the Mental Capacity Act. It has been widely recognised that there are number of challenges associated with the current DoLS system, particularly in light of the increases in the number of DoLS applications – which have been seen across England and Wales. In light of the UK Government decision, we will need to consider how we strengthen the current DoLS system in order to continue to protect and promote the human rights of those people who lack mental capacity. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/liberty-protection-safeguards-mca or email frida@hc-uk.org.uk. hub members receive 20% off. Email info@pslhub.org for discount code. Follow the conference on Twitter @HCUK_Clare #LPS2023
  7. Event
    This one day virtual masterclass facilitated by Mr Perbinder Grewal, will focus on how to deal with difficult people. Do you have someone at work who consistently triggers you? Doesn’t listen? Takes credit for work you’ve done? Wastes your time with trivial issues? Acts like a know-it-all? Can only talk about themselves? Constantly criticises? We will discuss strategies and tools to improve communication and interactions with others. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/how-to-deal-with-difficult-people or email aman@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.
  8. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/systems-based-solutions-patient-safety-masterclass or email frida@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org
  9. Event
    The Patient Safety Strategy (2019) and Patient Safety Investigation Framework (PSIRF) both outline a fundamental shift in the way that patient safety investigations are conducted. This ‘new era’ in patient safety represents a considerable shift in the way that investigations are conducted, particularly for those NHS Trusts implementing PSIRF. As the Serious Incident Framework (2015) becomes obsolete, how teams select their incidents to investigate will shift away from severity of harm to focusing on pinpointing opportunities to maximising learning. Indeed, under the new arrangements, teams are encouraged to consider utilising a wider range of investigation techniques that will ensure a more proportionate and potentially less time-consuming approach to understanding sub-standard care and failings. With an emphasis on systems thinking and human factors, organisations will need to identify and train expert investigators. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/psirf-masterclass or click on the title above or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.
  10. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/systems-approach-patient-safety-masterclass or email frida@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.
  11. Event
    The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework. This national conference looks at the practicalities of Serious Incident Investigation on and Learning and how this has changed with the publication of PSIRF. The conference will also update delegates on best practice in serious incident investigation under PSIRF and ensuring the focus is on learning from improvement. There will also be a extended focus on learning, including mortality governance and learning from deaths ensuring insight and investigation findings lead to improvement. The conference will include updates from PSIRF early adopter sites. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email frida@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #NHSSeriousIncidents
  12. Event
    This masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key learning objectives: Understanding the role of the Senior Information Risk Owner Identifying Information Risks across the organisation Working with others to mitigate the risk to patients, staff and organization. Confidence that all reasonable technical and organisation measure are in place Giving assurance to the Board that risks have been considered, mitigated or owned Understand the requirements of external confidence that policies, procedures are in place to deal with Data Breaches. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/masterclass-developing-your-role-as-a-senior-information-risk-owner-siro or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for a discount code.
  13. News Article
    An inspection of an ‘outstanding’ hospital has revealed concerns about unsafe staffing, as well as bullying and undermining behaviour. The then Health Education England issued Frimley Health Foundation Trust 14 mandatory requirements after visiting its Frimley Park Hospital in March to look at training in medical specialties. The risk-based review followed concerns in the 2022 national training survey and previous quality interventions by HEE. Among the problems HEE was told about were: Junior doctors feeling staffing on some shifts was unsafe. Foundation year one doctors were sometimes the only doctors on a ward, while one foundation doctor spent their first weekend on call looking after two wards by themselves. Concerns about bullying and undermining behaviour in an unnamed department, and consultant behaviour during weekend handover which left some staff feeling “uncomfortable”. Read full story (paywalled) Source: HSJ, 11 July 2023
  14. Event
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    The final tweetchat in the 'Six lessons for leading improvement' campaign.
  15. News Article
    Pharmaceutical giants are pouring tens of millions of pounds into struggling NHS services – including paying the salaries of medical staff and funding the redesign of patient treatment – as they seek to boost drug sales in the UK, the Observer can reveal. The spending is revealed in an investigation that lays bare the growing role of Big Pharma in the UK’s health sector, with analysis of more than 300,000 drug company transactions since 2015 showing a surge in spending on activities other than research and development (R&D). Payments to UK health professionals and organisations, including donations, sponsorship, consultancy fees and expenses, reached a record £200m in 2022, excluding R&D with companies seeking to promote lucrative drugs for obesity, diabetes and heart conditions among the biggest spenders. The rise in spending raises concerns about the growing influence of pharmaceutical companies in the NHS as it reaches its 75th anniversary milestone. Amid record pressure on services, drug giants say closer collaboration can help deliver major benefits to patients. NHS England said collaborations with industry helped patients “benefit from faster access to innovative treatments” and that it was “not unusual for industry to provide funding to support service delivery in areas such as improving cardiovascular health, tackling infectious disease or rolling out innovative cancer therapies”. It added that “strict safeguards” were in place for managing conflicts of interest. Read full story Source: The Guardian, 8 July 2023
  16. News Article
    Nearly half of all NHS hospital maternity services covered so far by a national inspection programme have been rated as substandard, the Observer can reveal. The Care Quality Commission (CQC), which regulates health and care providers in England, began its maternity inspection programme last August after the Ockenden review into the Shropshire maternity scandal, which saw 300 babies left dead or brain damaged by inadequate NHS care. Of the services inspected under the programme, which focuses on safety and leadership, about two-thirds have been found to have insufficient staffing, including some services that were rated as good overall. Eleven services saw their rating fall from their previous inspection. Dr Suzanne Tyler of the Royal College of Midwives said: “Report after report has made a direct connection between staffing levels and safety, yet the midwife shortage is worsening. Midwives are desperately trying to plug the gaps – in England alone we estimate that midwives work around 100,000 extra unpaid hours a week to keep maternity services safe. This is clearly unsustainable and now is the time for the chancellor to put his hand in the Treasury pocket and give maternity services the funding that is so desperately needed.” Read full story Source: The Guardian, 9 July 2023
  17. News Article
    A struggling trust has been warned by regulators that it could see its junior doctors removed, after concerns about clinical supervision and safety at a hospital whose A&E closes at night. NHS England inspectors who visited Cheltenham General Hospital found emergency patients – including potential surgical patients – became the responsibility of the overnight medical team when its accident and emergency closed in the evening. One night, 26 patients had been handed across, the inspectors were told, and some patients were felt to be inappropriate for medical referral. A surgical registrar could be telephoned at Gloucester Royal Hospital about surgical patients. They were told that although there were no incidents of serious harm, there had been many “near misses” and juniors felt “unsafe and unsupported in terms of consultant clinical supervision, overall clinical/nursing staffing support or logistically in managing patients in this setting or arranging transfers”. Read full story (paywalled) Source: HSJ, 7 July 2023
  18. News Article
    Daniel was about to get the fright of his life. He was sitting in a consulting room at the Royal Free hospital in London, speaking to doctors with his limited English. The 21-year-old street trader from Lagos, Nigeria, had come to the UK days earlier for what he had been told was a "life-changing opportunity". He thought he was going to get a better job. But now doctors were talking to him about the risks of the operation and the need for lifelong medical care. It was at that moment, Daniel told investigators, that he realised there was no job opportunity and he had been brought to the UK to give a kidney to a stranger. "He was going to literally be cut up like a piece of meat, take what they wanted out of him and then stitch him back up," according to Cristina Huddleston, from the anti modern slavery group Justice and Care. Luckily for Daniel, the doctors had become suspicious that he didn't know what was going on and feared he was being coerced. So they halted the process. The BBC's File on 4 has learned that his ground-breaking case alerted UK authorities to other instances of organ trafficking. Read full story Source: BBC News, 4 July 2023
  19. Content Article Comment
    @richard vA now fixed.
  20. News Article
    The head of NHS England has warned that July's planned strikes in the health service could be the worst yet for patients. Amanda Pritchard said industrial action across the NHS had already caused "significant" disruption - and that patients were paying the price. This month's consultant strike will bring a "different level of challenge" than previous strikes, she said. Junior doctors and consultants will strike for a combined seven days. Ms Pritchard told the BBC's Sunday with Laura Kuenssberg programme that the work of consultants - who are striking for the first time in a decade - cannot be covered "in the same way" as junior doctors. "The hard truth is that it is patients that are paying the price for the fact that all sides have not yet managed to reach a resolution," she said. Read full story Source: BBC News, 2 July 2023
  21. News Article
    NHS whistleblowers need stronger legal protection to prevent hospitals using unfair disciplinary procedures to force out doctors who flag problems, the British Medical Association has said. Doctors are being “actively vilified” for speaking out, which has resulted in threats to patient safety, including unnecessary deaths, according to the council chair of the doctors’ union, Phil Banfield. Despite a series of scandals in recent years, it is becoming more common for hospitals to use legal tactics and “phoney investigations” to undermine or force out whistleblowers rather than address their concerns, he warned. Banfield said: “Someone who raises concerns is automatically labelled a troublemaker. We have an NHS that operates in a culture of fear and blame. That has to stop because we should be welcoming concerns, we should be investigating when things are not right. “Whistleblowers are pilloried because some NHS organisations believe the reputational hit is more dangerous than unsafe care,” he added. “Whereas the safety culture in aviation took off after some high-profile airplane crashes in the 70s, the difference is that the aviation industry embraced the need to put things right and understand the systems that led to the disaster – the NHS has not invested in solving the system, it’s been bogged down in blaming the individual instead of the mistake.” Read full story Source: The Guardian, 2 July 2023
  22. News Article
    Nearly 170,000 workers left their jobs in the NHS in England last year, in a record exodus of staff struggling to cope with some of the worst pressures ever seen in the country’s health system, the Observer can reveal. More than 41,000 nurses were among those who left their jobs in NHS hospitals and community health services, with the highest leaving rate for at least a decade. The number of staff leaving overall rose by more than a quarter in 2022, compared to 2019. The figures in NHS workforce statistics of those leaving active service since 2010 analysed by the Observer show the scale of the challenge facing prime minister Rishi Sunak. He launched a new workforce plan on Friday to train and keep more staff. Sir Julian Hartley, chief executive of NHS Providers, said: “Staff did brilliant work during the pandemic, but there has been no respite. The data on people leaving is worrying and we need to see it reversed. “We need to focus on staff wellbeing and continued professional development, showing the employers really do care about their frontline teams.” Read full story Source: The Guardian, 1 July 2023
  23. News Article
    A Colorado surgeon has been convicted of manslaughter in the death of a teenage patient who went into a coma during breast augmentation surgery and died a year later. Emmalyn Nguyen, who was 18 when she underwent the procedure 1 August 2019, at Colorado Aesthetic and Plastic Surgery in Greenfield Village, near Denver, fell into a coma and went into cardiac arrest after she received anaesthesia, officials said. She died at a nursing home in October 2020. Dr. Geoffrey Kim, 54, a plastic surgeon, was found guilty of attempted reckless manslaughter and obstruction of telephone service. At Kim’s trial, a nurse anesthetist testified that he advised Kim that the patient needed immediate medical attention in a hospital setting and that 911 should be called, prosecutors said. An investigation determined Kim failed to call for help for five hours after the patient went into cardiac arrest, prosecutors said. The obstruction charge was linked to testimony that multiple medical professionals, including two nurses, requested permission to call 911 to transfer care for Nguyen, but Kim, the owner of the surgery centre, denied the request, prosecutors said. Read full story Source: ABC News, 15 June 2023
  24. Event
    This session will focus on blood and bodily fluids exposure, including sharps injuries as well as their risk factors and prevention strategies. This webinar will present the 2020 RCN study and the 2022 UK NHS Trust study of sharps injury (SI) among UK HCW and, by comparing these results with other countries, question whether UK 2013 Sharps Regulations went far enough, and whether increased emphasis may be required on reporting, recording and implementation of effective prevention strategies. Learning outcomes: Define sharps injuries (SI); the four steps in sharps usage that place staff at risk; and the top two staff groups at risk of SI. Discuss the incidence of SI in the UK and UK HCW staff groups compared with international incidences. Appraise whether facility’s reporting and recording of SI enables benchmarking of the efficacy of their preventive strategies. Define three prevention strategies proven to reduce SI. Register
  25. News Article
    An inquiry investigating deaths of mental health patients in Essex has been given extra powers, in a victory for campaigners. Health Secretary Steve Barclay told Parliament that the probe would be placed on a statutory footing. It means the inquiry can force witnesses to give evidence, including former staff who have previously worked for services within the county. Mr Barclay said he was committed to getting answers for the families. He told the Commons: "I hope today's announcement will come as some comfort to the brave families who have done so much to raise awareness." The Secretary of State added that under the new powers anyone refusing to give evidence could be fined. Melanie Leahy, whose son Matthew died while an inpatient at the Linden Centre in Chelmsford in 2012, is among those who have long campaigned for the inquiry to be upgraded. "Today's announcement marks the start of the next chapter in our mission to find out how our loved ones could be so badly failed by those who were meant to care for them," said Ms Leahy. "I welcome today's long overdue government announcement and I look forward to working with the inquiry team as they look to shape their terms of reference." Read full story Source: BBC News, 28 June 2023
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