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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. News Article
    A nine-year-old boy died from sepsis after doctors and nurses missed a "significant" GP note, an inquest heard. Dylan Cope, from Newport was taken to the Grange Hospital in Cwmbran, Torfaen, on 6 December 2022 after his GP wrote “query appendicitis”, but this note was not read. The senior doctor on shift that night said GP referrals were not being printed off and put into patients' notes because of how busy the department was. Read full story Source: BBC News 23 May 2024
  2. Content Article
    In this issue of BMJ Quality & Safety, Payne et al report patient safety issues arising during remote encounters, primarily telephone-based, in the primary care setting. Through qualitative interviews and observations, they examined why safety incidents occur and what can prevent safety incidents in developing a culture of safety. 
  3. Content Article
    The Australian Living Evidence Collaboration (ALEC) was established in 2018 to support and develop ‘Living’ evidence and guidelines – an approach that enables almost real time updating of the latest research and guidance without compromising the rigorous, gold standard methods needed to provide trustworthy recommendations. The initial focus areas were stroke, diabetes, arthritis and kidney disease. They support evidence-based clinical decision-making in priority areas for Australian health care settings. To do this they: convene the sector (clinicians, consumers, policymakers, organisations, researchers) to promote and build multidisciplinary collaboration provide living evidence syntheses develop living guidelines conduct research to improve their impact.
  4. Content Article
    In this blog Chris Dzikiti, Director of Mental Health at CQC, and Dr Jacqui Dyer, Mental Health Equalities Advisor at NHS England, talk about the work our two organisations are doing to implement the Patient and Carer Race Equality Framework (PCREF).
  5. Content Article
    In this article, published on LinkedIn, Charlotte John explains why digital transformation can be met with resistance and why those leading such projects need to understand why staff may not welcome the change.
  6. Event
    Wednesday 26 June at 12.00pm – 13.00 (online) Where we are and where we are going? Delivered by Dr Tracey Herlihey, Deputy Director of Patient Safety (Digital), NHS England. This seminar focuses on the Patient Safety Incident Response Framework (PSIRF). Click here to reserve your place
  7. News Article
    Across the world, medical tests are being adjusted according to patients’ skin colour – with shocking consequences. One science writer tells how she helped overturn one of the pernicious assumptions of race-based healthcare. Read full article Source: Guardian, 25 May 2024
  8. News Article
    The NHS has spent £4.1bn over the last 11 years settling lawsuits involving babies who suffered brain damage when being born, amid claims that maternity units are not learning from mistakes. It paid out just under £3.6bn in damages in 1,307 cases in which parents were left to care for a baby with cerebral palsy or other forms of brain injury, NHS figures reveal. NHS Resolution, which defends hospitals in England accused of medical negligence, spent another £490m on legal fees, taking the total cost of dealing with the legal actions to £4.1bn. Read full story Source: Guardian, 26 May 2024
  9. News Article
    The rising number of people ­waiting for physiotherapy treatment is causing problems in other parts of the NHS and harming the UK’s economy, leading clinicians have warned. Waiting lists for treatment for ­musculoskeletal (MSK) problems such as back, neck and knee pain have grown by 27% since January last year. The Chartered Society of Physiotherapy (CSP) said the number of physiotherapy posts in the NHS was not keeping pace with demand from Britain’s ageing and increasingly obese population. The CSP said the UK needed a 7% increase in NHS physiotherapy positions every year to meet rising demand. Musculoskeletal conditions that are left untreated can become more complex and lead to mental health problems or the need for surgery, as well as time off work. Read full story Source: Guardian, 26 May 2024
  10. News Article
    The NHS has today announced the 143 hospital sites that will test and roll out Martha’s Rule in its first year. Confirmation of the first sites to test implementation of Martha’s Rule is the next step in a major patient safety initiative, following the announcement in February of NHS England funding for this financial year. The purpose of Martha’s Rule is to provide a consistent and understandable way for patients and families to seek an urgent review if their or their loved one’s condition deteriorates and they are concerned this is not being responded to. Read full press release Source: NHS England
  11. News Article
    The number of coroner warnings issued last year which were linked to a lack of capacity in emergency care was around four times that seen before covid. HSJ analysis of “prevention of future deaths” reports – also known as Regulation 28 reports – show a steep rise since 2021 in deaths linked to long delays in ambulance responses, hospital handovers, and emergency department waits. There were 52 in this category in 2023. The largest number pre-covid was 13 in 2018, although the rate also appeared to be slowly rising in the years running up to 2020. Read full story (paywalled) Source: HSJ, 28 May 2024
  12. Content Article
    This blog is part of a series written by Dr Charlie*, taking a closer look at some of the patient safety issues affecting people's lives today. In this blog Dr Charlie tells us how their elderly mother was met with multiple digital barriers when trying to access her medications. Describing the situation as a frustrating goose-chase, Dr Charlie summarises the blog by questioning what measures are put in place to safeguard patients during digital transformations.  *not the authors real name
  13. Content Article
    This NHS England document sets out the roles and responsibilities of non-executive director roles.
  14. Content Article
    Deborah Filipek, author of this article for the Healthcare Financial Managment Assication (US), looks at research linking staff burnout to patient safety. Key points: Authors of two published studies reviewing clinician burnout found increased burnout affecting clinician mental and physical health and posing concerns for patient care and safety. One of the studies also looked at which interventions clinicians preferredImprovement in care delivery was rated by both physicians and nurses as more important to their mental health and well-being than interventions directed at improving clinicians’ mental health. On average, under single coverage, female employees have approximately $266 more in out-of-pocket spending per year than male employees, excluding pregnancy-related services. Only 227 American Indian/Alaska Native students entered U.S. medical schools during the 2021-22 academic year. Click on the link below to see the full article.
  15. Content Article
    In this blog, pushed by BMJ Opinion, David Gilbert, patient director, Sussex MSK Partnership (Central) looks at patient leadership.
  16. Content Article
    The objective of this paper, published in the BMJ, was to determine the effect of labour epidural on severe maternal morbidity (SMM) and to explore whether this effect might be greater in women with a medical indication for epidural analgesia during labour, or with preterm labour. Findings: Epidural analgesia during labour was associated with a 35% reduction in SMM, and showed a more pronounced effect in women with medical indications for epidural analgesia and with preterm births. Expanding access to epidural analgesia for all women during labour, and particularly for those at greatest risk, could improve maternal health.
  17. Content Article
    In this thought paper, Adrienne Fresko and Sue Rubenstein look at patient safety advice for boards from recently published guidance and research. 
  18. Event
    until
    How can you mitigate surgical errors in your operating theatre? What human factors would you consider in your planning? How does culture play a role in risk? Join Professor Peter Brennan, consultant surgeon at Queen Alexandra Hospital in Portsmouth, as he leads our upcoming webinar on human factors. Join the discussion on changing culture, minimising surgical errors and improving patient safety. Royal College of Surgeons (RCS) England members attend for free. Register here
  19. Content Article
    Recognising the profound impact of aortic dissection on loved ones and healthcare professionals, the team at Hull Royal Infirmary identified a critical need for improvement. As a result, the team has enhanced the diagnostic detection of aortic dissection by integrating Human Factors insights and leveraging the experiences of patients, earning them the 2023 Health Services Journal Patient Safety Award. Hull Royal Infirmary's innovative approach has significantly improved aortic dissection diagnosis, reducing missed cases and enhancing patient outcomes.
  20. Content Article
    The intended audience for these guidelines from the World Health Organization, is clinicians (doctors, nurses, Infection Prevention Control professionals, etc.) involved in the management of patients who require intravascular catheters. However, to ensure an appropriate, practical, clinical adherence to the guidelines, hospital administrators and other professionals involved in health care need to understand their importance and the focus of the recommendations to ensure appropriate support for clinicians. Patients are also part of the audience of these guidelines as they need to be generally informed about practices performed for their care and, in some cases, understand the choice of the intervention(s).
  21. News Article
    The NHS’s leading wheelchair provider has been told to urgently improve its complaints system by the health service ombudsman amid concerns disabled people are waiting up to two years for chairs. The parliamentary and health service ombudsman (PHSO) took the unusual step of writing to AJM Healthcare after a sharp rise in complaints from wheelchair users. Most related to people not receiving new wheelchairs or the correct parts. The waits range from a month to two years, the ombudsman said. Read full story Source: Guardian 21 May 2024
  22. News Article
    Rishi Sunak has promised to pay "comprehensive compensation" to people affected by the infected blood scandal. The prime minister said the government would pay "whatever it costs" following a damning report on the scandal, external, which saw 30,000 people infected. A public inquiry found authorities had exposed victims to unacceptable risks and covered up the NHS's biggest treatment disaster. The government will set out compensation details on Tuesday. Ministers have reportedly earmarked around £10bn for a compensation package. Read full story Source: BBC News, 21 May 2024
  23. News Article
    Prime Minister Rishi Sunak has apologised for the infection of around 30,000 people with contaminated blood products, and the failure to address the problem. Mr Sunak accepted the findings of Sir Brian Langstaff's inquiry report: "Was there a cover-up? Let me directly quote him - there has been". Watch the recording Source: BBC News, 20 May 2024
  24. Content Article
    Hugh Pym and Chloe Hayward speak about the Infected Blood Inquiry in this 30 minute piece from the BBC, one of the worst treatment disasters in NHS history. 
  25. News Article
    Pharmacists are calling for fresh powers to provide patients with alternative prescriptions as they warned that drugs shortages are hampering their ability to tackle whooping cough. More than 2,700 cases have been reported across England so far in 2024 – more than three times the number recorded in the whole of last year. But some pharmacies have been forced to turn away families seeking help for their children because they have run out of clarithromycin, a key antibiotic used to treat the condition. Read full story Source: Guardian, 20 May 2024
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