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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    More men than normal are dying at home from heart disease in England and Wales and more women are dying from dementia and Alzheimer's disease, figures show. More than 26,000 extra deaths occurred in private homes this year, an analysis by the Office for National Statistics found. In contrast, deaths in hospitals from these causes have been lower than usual. The Covid epidemic may have led to fewer people being treated in hospital or it may be that people in older age groups, who make up the majority of these deaths, may be choosing to stay at home – but the underlying reasons for the figures are still not clear. Read full story Source: BBC News, 19 October 2020
  2. News Article
    The large number of COVID-19 patients being admitted to hospitals at the centre of the second wave will “devastate” care for people with other illnesses, a top doctor has said. Dr Tristan Cope said Liverpool’s acute hospitals would not be able to continue providing normal care because of the high number of people being treated for serious Covid symptoms. Unless the surge in coronavirus admissions slowed down it would “have a devastating effect on planned care, such as operations”, he said. Cope is the medical director of Liverpool university hospitals NHS trust, where almost all critical care beds are already full because the city’s high infection rate has placed intense pressure on the trust’s three hospitals: the Royal Liverpool, Broadgreen and Aintree. “Liverpool hospitals are under enormous pressure with admissions of sick Covid patients. We are used to pressure, but this is over and above that,” Cope tweeted last week. “We have the highest number of Covid patients in the UK, nearly as many now as at the peak of the first wave. We also have more Covid patients in ICU [intensive care units] than any other trust in the UK.” Cope said: “If we don’t reduce the rate of infection in the community and Covid admission rates continue to rise, it will inevitably have a massive effect on non-urgent care." “If we don’t get control of [the] spread of the virus in the community and admissions continue at the current rate, our hospitals will not be able to cope. This will have a devastating effect on planned care, such as operations.” Read full story Source: The Guardian, 15 October 2020
  3. Content Article
    Harry Richford was born at the Queen Elizabeth the Queen Mother Hospital (QEQM), Margate, Kent on 2/11/17. He died on 9/11/17 at the William Harvey Hospital, Ashford to where he had been transferred. The cause of death was 1a Hypoxic Ischaemic Brain Encephalopathy. There was a narrative conclusion setting out some seven failures in the care of Harry Richford together with a conclusion that his death was contributed to by neglect.
  4. Content Article
    As an industry, biopharmaceuticals is immature when it comes to the integration of human performance into operations. This article from BioPhorum aims to accelerate the industry’s maturity by building a greater understanding of what is desired and explaining how to get there. Human performance is believed by many companies in the biopharmaceutical industry to be a focus on human error reduction, where work outcomes will improve by adding more requirements and coercing people to try harder to be infallible. This archaic approach is not sustainable today and is not human performance. The environment that we operate within – both externally and internally – is changing and yet we are still applying decades-old mental models of what good problem solving looks like, and how this drives overall performance and results. Human performance is the way to make a shift towards systems thinking. Without making this change, organisations will continue to stagnate and actually be unable to keep up with the increasing complexity of the environments they work in, and the environments they create. This blue-sky vision of human performance takes time and patience to properly implement and must be viewed as a fundamental change to how an entire organisation executes work. Essentially, this is a transformation of the organisation’s systems and thinking over a period of several years. This article provides guidance that has worked within the biopharmaceutical industry and the unique regulatory space it operates within.
  5. Content Article
    Doctors who contracted COVID, and thought the symptoms would be over in weeks, tell Jennifer Trueland about their continuing pain, exhaustion and – sometimes – struggle to be believed
  6. Content Article
    The stark and enduring inequality in mental health outcomes between black and white people is being addressed by two psychiatrists who want to tackle decades of unfounded assumptions. Keith Cooper reports
  7. Content Article
    Browse or search for publications about the development and use of SOPS surveys and other topics related to assessing patients’ experiences with care.
  8. News Article
    When the pain in her shoulders and weakness in her right leg started two years ago, Giovanna Ippolito thought it was just part of getting older — that's until the 46-year-old's doctor ordered an X-ray that showed a five-centimetre long, broken needle embedded in her spine. It was a medical error that took more than a decade to discover — after medical staff at the time failed to report it. Exactly when the needle was left in Ippolito's spine is unclear, but she says she's only had something injected into her back twice — during the birth of her son in 2002 and her daughter in 2004. Ippolito says she believes the needle broke off when medical staff at Mackenzie Richmond Hill Hospital in nearby Richmond Hill (called York Central Hospital at the time) administered a spinal block or an epidural during one of the births. She's now locked in a battle with the hospital for answers and accountability. But experts say, with a system that's stacked against Canadians harmed by medical errors, it's likely no one will have to take responsibility. More than 132,000 patients experienced some kind of medical harm — something both preventable and serious enough to require treatment or a longer hospital stay — in 2018-19, according to the Canadian Institute for Health Information, an independent, not-for-profit organization that collects information on the country's health systems. Read full story Source: CBC, 5 October 2020
  9. Content Article
    The COVID-19 pandemic has had far-reaching effects upon people’s lives, health care systems and wider society. As yet there is little research into the number of people at risk of developing ongoing COVID-19. Early attention has been on the acute illness generated by the virus, but it is becoming clear that, for some people,COVID-19 infection is a long term illness. This rapid and dynamic review authored by Dr Elaine Maxwell draws on the lived experience of patients and expert consensus as well as published evidence to better understand the impact of ongoing effects of COVID19, how health and social care services should respond, and what future research questions might be.
  10. Event
    Whether your role is in the NHS or in private healthcare, it is vitally important to take consent for any intervention safely. This webinar brings together clinical and legal perspectives, advising healthcare professionals of all levels how to take consent safely to avoid litigation and improve patient safety. Receive guidance from NHS Consultant, Michael Kelly, who has provided expert witness evidence at Court, combined with input from Andrew Bershadski, a highly experienced Barrister who has proceeded to Trial and won for the medical profession on a number of separate informed consent cases. Ed Glasgow, a Partner specialising in Healthcare Law, will Chair the event, which it is hoped will provide valuable practical insight.
  11. Content Article
    The State of Care is the Care Quality Commission (CQC) annual assessment of health care and social care in England. The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve. The care that people received in 2019/20 was mostly of good quality. But while the quality of care was largely maintained compared with the previous year, there was generally no improvement overall. And in the space of a few short months since then, the pandemic has placed the severest of challenges on the whole health and care system in England.
  12. News Article
    The government must immediately deliver a new deal for social care with major investment and better terms for workers, the Care Quality Commission (CQC) has said, as it warned that the sector is “fragile” heading into a second wave of coronavirus infections. In a challenge to ministers, the regulator’s chief executive, Ian Trenholm, said overdue reform of the care sector “needs to happen now – not at some point in the future”. Boris Johnson said in his first speech as prime minister, in July 2019: “We will fix the crisis in social care once and for all.” But no reform has yet been proposed, and more than 15,000 people have died from COVID-19 in England’s care homes. Trenholm said Covid risked turning inequalities in England’s health services from “faultlines into chasms” as the CQC published its annual State of Care report on hospitals, GPs and care services. The report reveals serious problems with mental health, maternity services and emergency care before the pandemic, and says these areas must not be allowed to fall further behind. The regulator argued that the health system’s response to the pandemic needs to change. After focusing on protecting NHS services from being overwhelmed, health leaders must now adapt to prevent people who need help for non-Covid reasons from being left behind, it said. These include people whose operations were cancelled and people from black and minority ethnic backgrounds, people with disabilities, and people living in deprived areas who have suffered more severely from the impact of Covid. “Covid is magnifying inequalities across the health and care system – a seismic upheaval which has disproportionately affected some more than others,” said Trenholm. Read full story Source: The Guardian, 16 October 2020
  13. News Article
    Leaking vials and suspected contamination were identified in a batch of more than 500,000 test tubes produced for the NHS Covid test and trace operation over the summer, whistleblowers have said. The test tubes were provided by a small UK-based company, Life Science Group (LSG), which produces materials for the diagnostics industry. According to the whistleblowers, there have been repeated problems with test tubes filled by LSG leaking. Stocks of some 600,000 test tubes were inspected in August as a result, and records seen by the Guardian describe the discovery of what looked like hair and blood contamination. It is understood firms in the supply chain concluded that the contamination was not hair or blood, following inspections. However, records seen by the Guardian suggested at least one bag of LSG test tubes thought to be contaminated “cannot now be found”. The whistleblowers said that rather than rejecting the entire potentially compromised batch, as would be normal safety protocol with NHS supplies, only part of the batch with visible problems was removed from use. They said they had blown the whistle because they were concerned for public safety. Read full story Source: The Guardian, 16 October 2020
  14. News Article
    A group of experts in nursing and infection prevention and control (IPC) is today warning against the use of IPC measures as a “rationale” for stopping safe and compassionate visits in care homes during the Covid-19 pandemic. In a new open letter published in Nursing Times, the specialists say that preventing people from visiting loved ones in social care settings in the name of IPC is a “misinterpretation and at times even abuse” of IPC principles. The letter is the brainchild of independent global health consultant and former Infection Prevention Society (IPS) president, Jules Storr. Among the signatories are five former IPC presidents, current president Pat Cattini as well as incoming president Jennie Wilson. Dr Ron Daniels, chief executive of the UK Sepsis Trust, is also on the list, Helen Hughes, chief executive of Patient Safety Learning, as well as leading IPC nurse specialists, nurse academics, a GP and carers. Ms Storr, a nurse by background, and the hub topic lead, said she was motivated to take action after hearing “the most heart-breaking” stories from health professionals and relatives of residents about restricted visits in the UK in the wake of COVID-19. Some had not seen relatives for weeks or months, whilst others were only allowed to see their loved one once a week for 20 minutes at a distance, she said. One individual had told her how when their father had died only one family member was permitted in the home and they were not allowed to sit close enough to hold his hand. Ms Storr said these practices were “absolutely outrageous and wrong from an infection prevention point of view”. Read full story Source: Nursing Times, 16 October 2020
  15. Content Article
    An open letter has been published in the Nursing Times from infection prevention and control experts, together with interested and concerned individuals and organisations, about the restrictions enforced in nursing, care and residential homes. Restrictions are being imposed in relation to COVID-19 across too many nursing, care and residential homes in the UK and beyond, in the name of infection prevention and control. A number of experts in this field, led by Jules Storr, independent global health consultant and former Infection Prevention Society (IPS) president, summarise in an open letter why infection prevention and control should be an enabler not a barrier to safe, compassionate human interaction in nursing, care and residential homes. By adding their voice their intention is to accelerate action to end this uncompassionate treatment of people in homes as well as for their families and other loved ones.
  16. Content Article
    On the 12 October 2020, the Care Quality Commission (CQC) announced the launch of a review into the imposition of blanket ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) notices for patients in care homes, primary care and hospitals. This follows revelations earlier in the year that potentially thousands of patients were being placed in care homes with blanket ‘do not attempt resuscitation’ (DNAR) notices in place. This has led to widespread public criticism. This article explores whether a DNACPR notice is valid without the consultation of family members or other representatives of a patient receiving care and, if not, what should be done?
  17. Content Article
    Patients collectively made Long Covid – and cognate term ‘long-haul Covid’ – in the first months of the pandemic. Patients, many with initially ‘mild’ illness, used various kinds of evidence and advocacy to demonstrate a longer, more complex course of illness than laid out in initial reports from Wuhan. Long Covid has a strong claim to be the first illness created through patients finding one another on social media: it moved from patients, through various media, to formal clinical and policy channels in just a few months. This initial mapping of Long Covid – by two patients with this illness – focuses on actors in the UK and USA and demonstrates how patients marshalled epistemic authority. Patient knowledge needs to be incorporated into how COVID-19 is conceptualised, researched, and treated.
  18. Content Article
    This report, written in collaboration with the Royal College of Nursing (RCN), sets out proposals to reduce the number of preventable natural deaths in prisons. It identifies how natural deaths occurring in prison might be prevented, where possible, and end-of-life care managed with dignity and compassion.
  19. Content Article
    This report from the Samaritans finds that there is no consistently effective support available to people who self-harm. The research identified four key support needs for people who self-harm, which are seen as essential to providing effective care: distraction from immediate self-harm urges emotional relief in times of stress developing alternative coping strategies addressing the underlying reasons for self-harm.
  20. News Article
    GPs’ warnings about restricted services may have put patients off seeking treatment, delaying diagnoses and worsening existing illnesses, the health and care watchdog has said. The Care Quality Commission (CQC) said that millions of people had struggled to see their doctors during the pandemic, which had magnified inequalities and risked “turning fault lines into chasms”. Between March and August 119.5 million GP appointments were made in England, down from 146.2 million last year, according to NHS Digital. Ian Trenholm, the CQC’s chief executive, said: “The number of lost GP appointments translates into millions of people potentially . . . not getting conditions diagnosed early enough, not getting those referrals on for diagnoses like cancer and other conditions.” Read full story (paywalled) Source: The Times, 16 October 2020
  21. Content Article
    From acute delirium to long term fatigue, COVID-19 has serious neuropsychiatric effects. Viral infections of the respiratory tract can have multisystemic effects, including on the central nervous system (CNS), and thus may precipitate a spectrum of psychiatric and neurological disorders. Some patients with COVID-19 are now known to develop various CNS abnormalities with potentially serious and long term consequences, including stroke and isolated psychiatric syndromes. As COVID-19 cases rise again worldwide, Butler et al. review what we know and don’t know about the acute and chronic neuropsychiatric sequelae and their potential mechanisms.
  22. Content Article
    Providers deliver: Resilient and resourceful through COVID-19 is the third report from NHS Providers which celebrate and promote the work of NHS trusts and foundation trusts in improving care for patients and service users. This report showcases eight examples of great ideas put into action by trusts through the dedication and ingenuity of staff. One of the main themes in the report is the value of staff empowerment, where trust leaders support ideas and approaches developed within their workforce. Other themes such as innovation and collaboration also emerge. The case studies in this report are a timely reminder of the resilience and resourcefulness that has characterised the response of trusts and their staff to the challenges posed by the pandemic.
  23. Content Article
    The safety huddle has become an important way for hospitals to surface safety concerns affecting patients and the workforce. The best huddles are multidisciplinary, highly structured, brief (15 minutes or less), take place early in the morning and focus on incidents from the day before and risks to safety in the day ahead. Is the safety huddle effective? Have organisations grown lax with the process over time? Some participants have observed that, over time, safety huddles tend to become "just another meeting" or "another box to check off." Dr. James Reinertsen, who has spent decades coaching clinical leaders and staff about safety, says too many huddles allow department leads to report "no safety issues today." That's impossible, says Reinertsen. Every department has safety risks; it's a matter of being proactive and looking for them. In this podcast, Ronette Wiley shares the story of the turnaround with the safety huddle and the tools they use at Bassett Medical Center in upstate New York, USA, and Dr Helen Mackie educates us about the safety huddle at Hairmyres Hospital in Scotland where issues are flagged daily in a rigorous process known as The Onion. 
  24. Content Article
    Parents know better than anyone if their child is not behaving as they usually do or seem different in some way. Studies have shown that caregivers are often the first people to spot changes in the health of their child, even when in a clinical environment. You should feel able to raise any concerns if you think something is ‘just not right’ with your child. Great Ormond Street Hospital has produced guidance on what to look out for and how to raise a concern if you are worried about your child when in hospital.
  25. Content Article
    People aged under 60 who are hospitalised with COVID-19 are more likely than expected to experience severe psychiatric symptoms. Research found that altered mental states such as psychosis are being reported in these younger patients. It confirmed that strokes and other neurological symptoms are common in severe COVID-19. The authors are gathering and analysing more detailed clinical information about the patients reported in this study, and others reported since (540 are now included). They are seeking funding for a further study to include more clinical investigations such as analysis of spinal fluid, blood and brain imaging. Author Benedict Michael is co-chairing a World Health Organization commissioned task force which will consider how to use the information from the ongoing research project in guidance for clinicians. The task force will consider whether people with new-onset altered mental state or another acute neurological problem should be tested for COVID-19. Some patients with few respiratory signs present with this symptom. They will consider which tests and investigations people with COVID-19 and neurological symptoms should undergo. Doctors need to be sure COVID-19 is the cause of the symptoms, and to know how patients should be managed.
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