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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Over the last five years, teams at Spectrum Health Helen DeVos Children’s Hospital in Grand Rapids, Michigan, had completed at least four different improvement projects focused on increasing adherence to the independent double check (IDC) process. An IDC is when two registered nurses independently check a medication to ensure it is correct prior to administering it to the patient. Like other institutions, the hospital did not require this process for all medications but did require it for a select group of medications considered higher risk if given in incorrect doses, routes or times.
  2. Content Article
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  3. Content Article
    Mrs Hazel Fleur Wiltshire was admitted to the Princess Royal University Hospital on 14 January 2021 following a fall at home. Although she had a number of factors indicating a risk of further falls, no risk assessments were completed on three wards and there was no evidence that measures that could mitigate the risk of falls were considered. Mrs Wiltshire's toileting care plan indicated that she was to be assisted with her toileting needs and she had access to a call bell. However, there were lengthy delays in responding to the call bell and on the night of 22 January 2021 she tried to re
  4. Content Article
    Nursing Matters: Patient safety – learning from our mistakes on Apple Podcasts Patient safety – learning from our mistakes - Nursing Matters | Podcast on Spotify
  5. Content Article
    The matrix describes the key elements of quality assurance along the y-axis, and graduations of ‘maturity’ along the x-axis. For each of the key elements, we have identified indicative statements so that organisations can self-assess their level of ‘maturity'. The rate of progress is incremental and the organisation cannot progress to the next level of maturity unless all criteria from the previous box have been fulfilled and, importantly, can be evidenced. The matrix should be used to illustrate the current performance and to inform and agree on future developmental expectations. Fo
  6. News Article
    A patient died from a serious spinal injury after emergency staff incorrectly attributed his physical condition to his mental health issues, an inquest heard. Robert Walaszkowski, who had been detained at a secure mental health unit run by North East London Foundation Trust in October 2019, suffered a serious injury after running into a door on the unit. Staff from London Ambulance Service did not suspect a spinal injury and he was taken to the emergency department at Queen’s Hospital in Romford with a suspected head injury. An inquest heard he did not receive a spinal examination an
  7. News Article
    NHS trusts in London are looking to dilute their intensive care nurse-to-patient ratios due to workforce shortages, according to a leading critical care nurse. Nicki Credland, chair of the British Association of Critical Care Nurses, told HSJ’s Patient Safety Congress that trust leaders in London have discussed relaxing the ratios from one nurse per patient, to one nurse per 1.75 patients. ICU staffing ratios have been intermittently diluted throughout the covid pandemic, but this has previously been used as a temporary measure. Ms Credland, a keynote speaker at the event on Tue
  8. News Article
    A TikTok user who went viral with a video of herself removing her implanted birth control device has prompted calls among sexual health experts for better monitoring of social media platforms. In a video which has gained over 178,000 likes, TikTok user Mikkie Gallagher is filmed performing a ‘DIY IUD removal’ wearing medical gloves, writing on top of the post: “A lot easier than I thought TBH,” and “Catch of the day: Mirena IUD, 2 inches”. An intrauterine device (IUD) is inserted into the uterus to prevent pregnancy and sometimes assist in relieving period pain. They usually need to
  9. News Article
    The return of schools and the arrival of autumn means common colds and other respiratory infections are firmly on the rise, spreading coughs and sneezes, more severe illnesses, and prompting some to report their worst colds ever. According to Public Health England, there is no particularly nasty new virus doing the rounds, but as cases rise, experts warn that people can expect more frequent infections and more serious symptoms now the UK is emerging from lockdown. Common colds and other respiratory tract infections tend to ramp up in September when the schools go back and autumn arri
  10. News Article
    It could take more than a decade to clear the cancer-treatment backlog in England, a report suggests. Research by the Institute for Public Policy Research (IPPR) estimated 19,500 people who should have been diagnosed had not been, because of missed referrals. If hospitals could achieve a 5% increase in the number of treatments over pre-pandemic levels, it would take until 2033 to clear the backlog. However, if 15% more could be completed, backlogs could be cleared by next year. Between March 2020 and February 2021, the number of referrals to see a specialist dropped by nearly 3
  11. News Article
    A coroner has raised concerns about how a family was allowed to bring a restricted item that contributed to a man's death into a mental health unit. Joshua Sahota, 25, died as a result of asphyxia and psychosis in Bury St Edmunds, Suffolk, on 9 September 2019. Suffolk coroner Nigel Parsley said Mr Sahota's relatives were not told the item they brought in when visiting was on a restricted list. The NHS trust which runs the unit said it had improved its internal processes. Mr Sahota, from Kennett in Cambridgeshire, was taken to the Wedgewood Unit on the West Suffolk Hospital
  12. Content Article
    Joshua Sahota had been admitted to Southgate Ward at Wedgewood House on 9 August 2019 following a stay as an inpatient at Addenbrookes Hospital, where he had been seen by a psychiatrist and deemed to be at a continuing high risk of self-harm. His family were asked to take fresh clothes to the Southgate Ward, which they did so in a plastic carrier bag. It had not been communicated to them that this was a ‘restricted item’ on the ward. Joshua was subsequently transferred to Northgate Ward, also within Wedgewood House, on the 15 August 2019. On the 9 September 2019, Josh was found in his roo
  13. Content Article
    Each report seeks to increase the number of people living with dementia with a diagnosis by: reducing regional variation in diagnosissupporting those from an ethnic minority community to access a diagnosisincreasing diagnosis for people residing in a care home or hospital setting.The reports set out a roadmap in how to achieve this change. But a diagnosis is not done in isolation. It requires all health and social care professionals involved in dementia care to recognise the symptoms of dementia and to initiate the process to diagnosis, which itself facilitates access to vital care and support
  14. Event
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    The aim of this day is to further enhance the understanding of delegates in the causes of surgical wound breakdown, the recognition and management of wound infection and the management of dehisced surgical wounds. Learning Objectives At the end of this study day, delegates will have: An awareness of national guidance and best practice with regard to prevention of surgical wound infection. A good understanding of how to recognise unusual signs of infection in surgical wounds including wound swabbing, how to do it when and why. A basic understanding of NPWT (Negativ
  15. Image Comment
    Left is Calcium Gluconate solution, the right is Sodium Chloride solution. In a reply to the tweet asking why this was a concern the doctor said: "One is a calcium based drug that could be really dangerous if given in too large quantities... The other is a saline solution that we often given as a flush after injecting other medications and things through a cannula."
  16. Image Comment
    Why isn't the generic name on medication labelling bigger than the trade and company name to make it easier to read?
  17. Content Article
    Putting quality and safety above all else is the first NHS Wales core value. This focus has been strengthened more recently through the Health and Social Care (Quality and Engagement) (Wales) Act (2020), the National Clinical Framework for Wales (2021) and the Quality and Safety Framework (2021). Collectively these set out an aspiration for quality-led health and care services, underpinned by prudent healthcare principles, value-based healthcare and the quadruple aim. In response, and in the context of the challenges at this stage of the pandemic and moving into a recovery phase, Improvement C
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