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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    How ambulance staff feel about their work has long been a concern, but the results of the latest staff survey show that their job satisfaction has deteriorated further. This blog from the Nuffield Trust takes a closer look at the findings and describes the importance of improving the situation.
  2. Content Article
    On the 18 October it was announced that NHS Trusts have been given an optional six-month extension to implement Learn From Patient Safety Events (LFPSE). There are a lot of messages being talked about and there has been some confusion over what this means. So, what do organisations need to have in place by 31 March 2023 and what has changed? In this blog*, Radar Healthcare cover some of the key information.
  3. News Article
    Voices offer lots of information. Turns out, they can even help diagnose an illness — and researchers in the USA are working on an app for that. The National Institutes of Health is funding a massive research project to collect voice data and develop an AI that could diagnose people based on their speech. Everything from your vocal cord vibrations to breathing patterns when you speak offers potential information about your health, says laryngologist Dr. Yael Bensoussan, the director of the University of South Florida's Health Voice Center and a leader on the study. "We asked experts: Well, if you close your eyes when a patient comes in, just by listening to their voice, can you have an idea of the diagnosis they have?" Bensoussan says. "And that's where we got all our information." Someone who speaks low and slowly might have Parkinson's disease. Slurring is a sign of a stroke. Scientists could even diagnose depression or cancer. The team will start by collecting the voices of people with conditions in five areas: neurological disorders, voice disorders, mood disorders, respiratory disorders and pediatric disorders like autism and speech delays. This isn't the first time researchers have used AI to study human voices, but it's the first time data will be collected on this level — the project is a collaboration between USF, Cornell and 10 other institutions. The ultimate goal is an app that could help bridge access to rural or underserved communities, by helping general practitioners refer patients to specialists. Long term, iPhones or Alexa could detect changes in your voice, such as a cough, and advise you to seek medical attention. Read full story Source: NPR, 10 October 2022
  4. Content Article
    Corey Adams, Researcher at the Australian Institute of Health Innovation, shares the impact of trauma on the patient experience. Corey shares his personal story of trauma and how we can alleviate the negative effects of trauma by building a culture of safety, kindness, trust, and respect.
  5. Content Article
    It is time to end all forms of stigma and discrimination against people with mental health conditions, for whom there is a double jeopardy: the impact of the primary condition itself and the severe consequences of stigma. Many people describe stigma as ‘worse than the condition itself’. This Lancet Commission report is the result of a collaboration of more than 50 people globally. It brings together evidence and experience on the impact of stigma and discrimination and successful interventions for stigma reduction. The report is co-produced by people who have lived experience of mental health conditions and includes material to bring alive the voices of people with lived experience. The voices whisper or speak or shout in the poems, testimonies and the quotations that are featured.
  6. Gallery Image
    Noradrenaline and tranexamic acid.jpg
    Shared with hub by Dr Abigail Clark-Morgan: Images shared of our stocked noradrenaline ampules and tranexamic acid – these have been mixed up and we are looking to stock alternative volumes of noradrenaline to reduce the likelihood of confusion. The incident also highlighted the importance of checking all the ampules drawn up, drawing up your own medications at the point of administration and effective second checking. Part of our immediate response was to label the noradrenaline ampules to make them more obviously different (the purple ampules pictured below).

    © Healthcare UK

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  8. News Article
    A Northern Ireland hospital closed its doors to new admissions on Saturday night because conditions had become unsafe, a health chief has said. Jennifer Welsh, chief executive at the Northern Health Trust, said the situation in the emergency department (ED) at Antrim Area Hospital on Monday remained “extremely pressured”. A major incident was declared at the weekend when a high number of critically ill patients arrived in quick succession at the Co Antrim hospital, prompting the decision to temporarily close the doors to new admissions. Ms Welsh said there were 45 patients in the ED on Monday for whom a decision to admit had been made, but for whom no bed is available. She told the BBC Good Morning Ulster programme: “That would have been unthinkable about four or five years ago, we would have never seen numbers like that." She said: “We had a high number of people arriving. A very high number of patients in the department. “At the time we called the incident there were 131 patients and about 66 of them had a decision to admit and no bed available. “At that stage our resuscitation unit was already full, it was over full. “Then we got the news we had three more standby ambulances coming in. That is critically ill patients who had to be brought into our resuscitation department as quickly as possible and we simply could not cope. “The safest thing to do in those circumstances is to call the major incident, to effectively close the door and what that means is that people are conveyed to the next nearest emergency department to ensure they begin the urgent treatment that they need because we were not able to do that. “It was the right call to say that it was unsafe. It was unsafe at that time.” Read full story Source: The Independent, 14 November 2022
  9. News Article
    Whistle-blowers have described neglect, patient-on-patient assault and staff who bully colleagues and sleep on the job at a troubled mental health ward. Sources told a BBC investigation that a patient of 25-bed, mixed-gender Hill Crest Ward in Redditch, Worcestershire, suffered a broken jaw during one clash. They also claimed three nurses were "forced out" amid bullying behaviour. The NHS trust that runs Hill Crest said it believed changes there were having a positive impact. Accounts have been corroborated via five independent sources to whom the BBC spoke. They follow reports earlier this year of a fire and an incident in which staff locked themselves in an office when a patient ran around armed with boiling water and sugar. Additionally, one patient has provided the BBC with images alleged to show the effects of her battering herself out of desperation - without staff intervening. Sources also described staff being bullied, with one saying a nurse who particularly suffered had her resignation letter read out and mocked by tormentors. Sources independently complained of the workplace culture, with the BBC aware of explicit images bearing lewd comments about colleagues. Read full story Source: BBC News, 15 November 2022
  10. News Article
    A policy change to speed up hospital discharge could save the NHS more than £7bn over a decade, according to a government evaluation – but ministers have not funded it. A Department of Health and Social Care impact assessment of the Health and Care Act, passed earlier this year, says that wider use of discharge to assess could free up as many as 6,000 hospital beds and save the NHS £7bn by 2031, the equivalent of £800m a year. It adds: “The overall societal benefits of this would likely be higher as beds could be allocated to patients with more urgent health care needs.” The “discharge to assess” approach, which has been used on a temporary basis for several years and more widely during the pandemic – with government funding to back it – sees patients discharged more quickly, and provided with support at home while their long-term care needs are assessed. It was credited with significant reductions in the amount of time patients spent in hospital. Changes in the Health and Care Act were intended to remove legal obstacles to the approach, by revoking a requirement for an assessments be carried out before discharge, which often leads to delays in the patient leaving hospital. Read full story (paywalled) Source: 15 November 2022
  11. News Article
    Doctors and nurses are “absolutely frightened and petrified” about how bad this winter will be for the NHS in England, hospital bosses have revealed. Staff fear services will not be able to cope with a combination of flu, resurgent Covid, winter and the cost of living crisis damaging people’s health, and also the wave of looming strikes over pay. “People are genuinely scared,” said the chief executive of one acute NHS trust in England. “I’m talking to senior clinicians and consultants and nurses who are absolutely frightened and petrified about what’s potentially to come,” added the hospital boss, speaking on condition of anonymity. Staff are anxious because of “the potential for the impact of Covid and flu, the impact of industrial action, the impact of cost of living, the impact on people’s health from that, [and] the massive increases in mental health need, and the breakdown in primary care and social care.” Chiefs of other NHS trusts in England said they shared that gloomy prognosis. They are bracing themselves for having to curtail and cancel services on days when staff stop work over pay, including outpatient clinics and non-urgent surgery. The NHS will face an “onslaught” this winter, one said. Read full story Source: The Guardian, 15 November 2022
  12. News Article
    Trust leaders have raised concerns about other major unions striking on the same dates as the Royal College of Nursing in co-ordinated action, which would make avoiding disruption and harm ‘more hairy’. The concerns were raised after the Royal College of Nursing confirmed members at various trusts had voted in favour of unprecedented action last week, with Unison and a raft of other unions also balloting members on strike action this month and in December. Unison told HSJ co-ordinated action between itself, the RCN and the other health unions was “the best way to ensure industrial action is effective”. One senior trust leader said that while the RCN strike days would prove a major challenge, they predicted their trust would be able to cope with the fallout. But they said the challenge would get even “more hairy” if Unison members also walked out on the same dates – a prospect they feared likely. HSJ also understands that trust bosses have concerns about what will and won’t be classified as urgent and also about the emergency work to be carried out throughout a strike. One senior provider figure used the example of insulin injections, which are at present to be part of the urgent and emergency care activities to continue throughout a strike, and wound treatment services, which, at this stage, are not. They said: “If people don’t get those [insulin] injections twice a day, that person, by the end of 24 hours, will be in hospital [but] we are negotiating on [other areas] for example wound care. If you don’t dress people’s wounds at the right time, the worst situation is that a [deteriorating] wound means your leg has to be chopped off. At the moment, doing wound care is not being considered urgent care.” Read full story (paywalled) Source: HSJ, 15 November 2022
  13. Content Article Comment
    Thank you for sharing Richard. I've added the page to Learn: Royal College of Emergency Medicine: Safety Resource Centre - Emergency medicine - Patient Safety Learning - the hub (pslhub.org)
  14. News Article
    Care homes and hospitals will be forced to allow visitors under plans being drawn up by the government. Helen Whately, the care minister, said shutting out relatives showed a lack of humanity. Covid-19 rules mean some of the country’s most vulnerable people still cannot have loved ones at their bedside. Whately, who has told of her personal grief and frustration at being barred from visiting her critically ill mother, is now developing laws to give residents and patients a right to receive visitors. Although official visiting restrictions were dropped in the spring in England, there are still widespread reports of care homes and hospitals refusing to let in relatives or imposing stringent conditions that ministers do not believe are justified by public health guidance. Hundreds of care homes still refuse to accept visitors entirely, according to government figures, while others restrict residents to one relative at a time. Campaigners report residents losing weight because their relatives cannot go in to help them at mealtimes amid staff shortages. They also fear residents are being left in bed for long periods because staff know there will be no visitors to check on them. Whately said that she was “determined to fix” the issue, adding: “No one can be in any doubt now how much visits matter”. Read full story (paywalled) Source: The Times, 11 November 2022 Related reading on the hub: Visiting restrictions and the impact on patients and their families: a relative's perspective It’s time to rename the ‘visitor’: reflections from a relative
  15. News Article
    One of the country’s most senior doctors has said he is “desperate” to keep his elderly parents out of hospital, which he said are like “lobster traps”. Dr Adrian Boyle, president of the Royal College of Emergency Medicine, said hospitals are easy to get into but hard to get out of. His comments come after figures showed the number of patients in hospital beds in England who no longer need to be there has reached a new monthly high. An average of 13,613 beds per day were occupied by people ready to be discharged from hospital in October. That was up from 13,305 in September and the highest monthly figure since comparable data began in December 2021, according to analysis by the PA news agency. In an interview with the Daily Mail, Dr Boyle said: “Hospitals are like lobster traps – they’re easy to get into and hard to get out of. “If social care was able to do its job in the way we want it to, these poor people wouldn’t be stranded in hospital. “I have elderly parents and I’m desperate to keep them out of hospital. “For someone who is frail, hospital is often a bad place for them. They’re being harmed by being in hospital.” Read full story Source: The Independent, 14 November 2022
  16. News Article
    Patients have been asking to go to other hospitals rather than one where the ageing roof is being held up by more than 2,400 wooden and steel posts. The Queen Elizabeth Hospital in King's Lynn has already had to close four of its seven operating theatres because of concerns the ceiling could collapse. Alex Stewart, head of Healthwatch Norfolk, said some pregnant women have asked to go to other hospitals. The Queen Elizabeth Hospital (QEH) opened in 1980, one of seven hospitals built using a material called reinforced autoclaved aerated concrete (RAAC). The material has serious weaknesses and is deteriorating, with uncertainty over its structural integrity leading to more than £100m being spent this financial year on safety measures across the affected sites. Mr Stewart told BBC Radio 4's Today programme: "I think people are very frustrated, they're well aware that the hospital staff inspect the hospital on a daily basis, several times a day. "That said, we are aware of patients, for example, who are giving birth, who have asked to go to other hospitals because they're scared in case the roof might fall in on them." The hospital's interim chief executive, Alice Webster, said while four theatres have had to be closed, "potentially" there could be problems with the ceilings in the others. "We continue to monitor it on a daily basis," she said. "We're making sure our theatres are functioning longer, we're functioning at weekends and trying to manage the waiting lists that way." She added: "If we don't get a new hospital we will have to review all the services that we currently provide, but we won't be able to provide all the services that we currently do." Read full story Source: BBC News, 13 November 2022
  17. News Article
    Scientists are launching a trial screening programme for type 1 diabetes in the UK to detect the disease earlier and reduce the risk of life-changing complications. About 20,000 children aged between 3 and 13 are being invited to take part in the Early Surveillance for Autoimmune Diabetes (Elsa) study, with recruitment opening on Monday. The aim is to assess children’s risk of developing type 1 diabetes at the earliest stage possible to ensure a quick and safe diagnosis, and reduce the number being diagnosed when they are already seriously ill. Parth Narendran, a professor of diabetes medicine at the University of Birmingham, said: “As general population screening programmes for type 1 diabetes emerge around the world, we need to explore how best to screen children here in the UK.” Dr Elizabeth Robertson, the director of research at Diabetes UK, which is co-funding the study with the not-for-profit organisation JDRF, said: “Identifying children at high risk of type 1 diabetes could put them and their families on the front foot, helping ensure a safe and soft landing into an eventual diagnosis, avoiding DKA and reducing the risk of life-altering complications.” Read full story Source: The Guardian, 14 November 2022
  18. News Article
    A Guardian analysis has found that as many as one in three hospital beds in parts of England are occupied by patients who are well enough to be discharged, with a chronic lack of social care meaning many do not have suitable places to go. Barry Long's 91-year-old mother has Alzheimer’s and was admitted to Worthing hospital on 30 May after a minor fall. She was a bit confused but otherwise unhurt, just a bit shaken. Whilst in hospital, she caught Covid and had to be isolated, which she found distressing, and became increasingly disoriented. She was declared medically fit to be discharged but no residential bed could be found for her. Then, in August, she was left unsupervised and fell over trying to get to the toilet and she fractured her hip, which required surgery. Her hip was just about healed when she caught her shin between the side bars and the frame of the bed, cutting her shin so badly that she is being reviewed by a plastic surgeon to see if it needs a skin graft. "Since the operation, my mum is pretty much bedbound and lives in a state of confusion and anxiety", says Barry. "Her physical health and mental wellbeing have deteriorated considerably in the almost five months she has spent in the care of the NHS. She spends all day practically trapped in bed, staring into space or with her eyes shut, just rocking to and fro. She has little mental stimulation." Read full story Source: The Guardian, 13 November 2022
  19. News Article
    A senior doctor is to be removed from the medical register after she was found to have attempted to cover-up the circumstances of a young girl's death. Paediatrics consultant Dr Heather Steen was found to be unfit to practise after an investigation into the death of nine-year-old Claire Roberts in 1996. A medical tribunal examining the doctor's case ruled that the majority of allegations against her were true. Claire's mother said it was "just the start of getting full justice". "I am angry at Dr Steen for putting us through 26 years of mental torment," said Jennifer Roberts. At the time of Claire's death, her parents were told she had a viral infection that had spread from her stomach to her brain. But in 2018 a public inquiry determined that she had died from an overdose of fluids and medication caused by negligent care at the Royal Belfast Hospital for Sick Children. The inquiry also concluded there had been "cover up" and the girl's death had not been referred to the coroner immediately to "avoid scrutiny". The case was then put to the Medical Practitioners Tribunal Service (MPTS), which rules on doctors' fitness to practise. When the case reached the tribunal stage Dr Steen twice applied to be voluntarily removed from the medical register and was twice refused. Had that been successful the tribunal would have been halted as she would no longer have been a doctor. However the tribunal continued and examined allegations that between October 1996 and May 2006 Dr Steen "knowingly and dishonestly carried out several actions to conceal the true circumstances" of Claire. Read full story Source: BBC News, 11 November 2022
  20. News Article
    No formal risk assessment was done on a man who beat a fellow care home resident to death, a review has found. Alexander Rawson attacked 93-year-old Eileen Dean with a metal walking stick at a care home in south-east London. Mrs Dean suffered catastrophic injuries to her head and body and died later in hospital. A review found Fieldside Care Home in Catford did not provide the specialist mental health services that Rawson - who had a history of violence - needed. Rawson, who had a history of mental health problems caused by alcoholism, was 62 when he was placed in the home a few days before Christmas 2020. He was put in the room next to Mrs Dean and, in the first week of 2021, he went into her room at night and attacked her. In a review published on Friday, the Lewisham Safeguarding Adults Board said Rawson had been moved into the home after being an inpatient at a psychiatric unit run by the South London and Maudsley NHS Foundation Trust. The care home was the only place that agreed to take him after his discharge from hospital. In the months before he was moved into the care home, Rawson was involved in at least 34 recorded incidents of violence or threats to patients and health staff, including a threat to kill. Before he was placed in the home, no attempts were made to find out whether Rawson had come into contact with the criminal justice system over his behaviour, the report found. It states that the care home had asked about the risks Rawson posed before they took him and had been reassured by a social worker and medical staff. Read full story Source: BBC News, 12 November 2022
  21. Content Article
    The National Institute for Clinical Excellence (NICE) defines psychosocial assessment following self-harm as ‘a comprehensive assessment including an evaluation of the person’s needs, safety considerations and vulnerabilities that is designed to identify those personal psychological and environmental (social) factors that might explain an act of self-harm’. NICE advises that all people who self-harm should be offered a psychosocial assessment at an early stage. Psychosocial assessment should include biological factors alongside psychological and socio-environmental aspects and is often termed ‘biopsychosocial assessment’. The aim of this document from the Centre for Suicide Research is to provide clinicians with guidance to help them conduct a comprehensive psychosocial assessment. To support this, associated signposting to supporting evidence and useful reading is included.
  22. Content Article
    The APPG held their annual general meeting in Parliament. Baroness Cumberlege was re-elected as Co-Chair of the group and in light of Jeremy Hunt’s recent appointment as Chancellor of the Exchequer, Sharon Hodgson MP was elected as Co-Chair, having previously supported the Group as Vice-Chair over the last calendar year. Sharon is is an Officer of the APPG for Valproate and other Anti-Epileptic Drugs in Pregnancy and Vice-Chair of the All-Party Parliamentary Group on Surgical Mesh. The current serving Vice-Chairs were re-elected, with the addition of Baroness Ritchie also joining as Vice-Chair. The Group looked back on a year of significant activity and progress, including the appointment of Dr Henrietta Hughes as the first Patient Safety Commissioner in England, and agreed that a renewed focus on seeking the implementation of redress schemes should be a priority for the Group over the next year.
  23. Content Article
    The Surviving in Scrubs campaign, created by Dr Becky Cox and Dr Chelcie Jewitt, gives a voice to women in healthcare to raise awareness and end sexism, sexual harassment and sexual assault in healthcare. In this blog for the hub, co-founder Dr Chelcie Jewitt tells us more about the campaign.
  24. Content Article
    The Royal College of Emergency Medicine’s Safety Resources hub has information and resources about alerts, safety resources, safety in the Emergency Department and safety events. This page is managed by the Safer Care Committee, which is part of the Quality in Emergency Care Committee (QECC). The QECC has produced a series of strategy documents, explaining the role of RCEM, and these committees, in improving patient care.
  25. News Article
    Ambulances called to serious emergencies in the East of England, which encompasses Essex, have the longest waiting times of anywhere in the UK, according to new data. The East of England Ambulance Service, which serves the county of Essex, has the longest wait times for life-threatening injuries of anywhere in the country. Ambulances took an average of 11 minutes and 12 seconds to respond to category one calls - those for life threatening injuries - in the Essex region in October. That’s up from 10 minutes 49 seconds in September, and far longer than the 7 minute target set by the NHS. This means it’s also the longest category one response time of any ambulance service in England, as compared to the average wait time for ambulances across England as a whole, category one calls were responded to in an average of 9 minutes and 56 seconds. A spokesperson for the East of England Ambulance Service said: "Our service is under extreme pressure with many ambulances delayed outside hospitals and high call volumes. "To help us respond effectively we have increased our escalation state across the Trust. We urge the public to please support us by using our services wisely and only calling for life-threatening illnesses and injuries." Read full story Source: Essex Live, 10 November 2022
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