Jump to content
 View Profile  See their activity

  • Posts

    11,589

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

Everything posted by Patient Safety Learning

  1. Content Article
    Worldwide, most Caesarean sections (CS) are performed under neuraxial anaesthesia. However, neuraxial anaesthesia can fail and intraoperative breakthrough pain can occur. The aim of this study from Roofthooft et al. was to evaluate the incidence of breakthrough pain in consecutive CS and to describe the potential risk factors for breakthrough pain. In a two centre, prospective audit all CS performed under neuraxial anesthesia were included and the occurrence of breakthrough pain as well as all possible risk factors of breakthrough pain were recorded as well as the alternative anesthetic strategy.
  2. Content Article
    At the beginning of the pandemic, there was an important question to resolve: is coronavirus “airborne”? If it was, then this meant that the virus could transmit through the air from person to person, even over long distances, in indoor environments. We now know the answer is yes. In the 19th century diseases such as cholera and typhoid taught us the importance of water quality – coronavirus in the 21st century should provide that same realisation on the importance of air quality. Ideally, all indoor environments where people congregate should be fitted with modern, efficient ventilation systems that flush out potentially contaminated air and replace it with fresh, clean air continually. This would prevent the build-up of virus-containing aerosols and reduce the likelihood of transmission of covid-19 and other diseases such as influenza. With energy costs rising, it is vitally important to find methods of preventing virus transmission that are safe, quick to implement and affordable, writes Dr Alice Bunn in this HSJ article.
  3. News Article
    The share of referrals waiting more than three months for a diagnostic test — one of the key problems behind long waits for cancer treatment — is worse than at any point since February 2021, during the second national covid lockdown. NHS England data released this morning for September shows 12.4% of the 1.6 million awaiting a test had been on the list longer than 13 weeks. At the peak of June 2020, 32% waited more than 13 weeks, but the proportion dropped back beneath 1 in 10, in May 2021, as services ramped up activity following the impact of the major winter 2020-21 Covid wave. Echocardiography patients and those needing endoscopies had the highest proportion of patients waiting more than six weeks – these specialties jointly comprise about a third of the total national waiting list and had 48 and 38%, respectively, of their lists over six weeks. Katharine Halliday, president of The Royal College of Radiologists, said: ”Today’s cancer waiting times data is alarming. We know the longer patients wait for a diagnosis or treatment, the less their chance of survival. “Our members are clinical radiologists and clinical oncologists, and much of their work involves diagnosing and treating cancer. Today’s figures show the NHS in England would have to employ 441 radiology consultants, the equivalent of a 16% increase in the current workforce, in order to clear the six-week wait for CT and MRI scans in one month.” Read full story (paywalled) Source: HSJ, 10 November 2022
  4. News Article
    A nurse in the USA who called emergency services in response to staffing issues at Silverdale, Washington-based St. Michael Medical Center spoke out about her decision and the events leading up to the call. Kelsay Irby has been an emergency department charge nurse at the hospital for less than a year. On the 8 October, the night Ms Irby called emergency services for help, the ED was operating at less than 50% of its ideal staffing grid. Among the nearly 50 people in the hospital's waiting room were patients with cardiac or respiratory issues and children with high fevers — "all patients that made us very nervous to have in the lobby, unmonitored for extended periods of time," Ms. Irby said. The ED had one first-look nurse on the clock who was trying to keep up with patients checking in and could not supervise those waiting for care. After exhausting all other available options, Ms. Irby said she called emergency services' nonemergent line and asked the dispatcher if any crews were available to help ED staff. Ms. Irby was connected with a local fire chief who sent an emergency services crew to the hospital to monitor patients in the lobby, retake their vitals and do roll calls to ensure the ED team's patient list was accurate. Ms. Irby's actions made national headlines in the US as a dramatic example of the staffing issues hospitals nationwide are facing. "I didn’t recognize the impact of what I was doing that night," Ms. Irby wrote. "I was simply working my way down the list of possible sources of help for my coworkers and ultimately our patients." Read full story Source: Becker's Hospital Review, 8 November 2022
  5. News Article
    Thirty-three provider groups in the USA penned a joint letter to President Joe Biden this week warning of “gridlocked” hospital emergency departments that are threatening patients’ lives and the well-being of shorthanded healthcare workers. “In recent months, hospital emergency departments (EDs) have been brought to a breaking point. Not from a novel problem—rather, from a decades-long, unresolved problem known as patient ‘boarding,’ where admitted patients are held in the ED when there are no inpatient beds available,” provider associations including the American College of Emergency Physicians (ACEP) and the American Medical Association (AMA) wrote. “While the causes of ED boarding are multifactorial, unprecedented and rising staffing shortages throughout the healthcare system have recently brought this issue to a crisis point.” The issue of boarding “has become its own public health emergency” for adult and paediatric care alike, the latter of which is being driven by a spike in mental health visits and, more recently, a “triple threat” of flu, COVID-19 and respiratory illnesses that have backed up children’s hospitals. “If the system is already this strained during our ‘new normal,’ how will emergency departments be able to cope with a sudden surge of patients from a natural disaster, school shooting, mass casualty traffic event or disease outbreak?” the groups wrote. The letter included a handful of firsthand accounts solicited by ACEP from anonymous emergency physicians describing patients deteriorating or dying “during their tenth, eleventh or even twelfth hour of waiting to be seen by a physician.” Read full story Source: Fierce Healthcare, 10 November 2022
  6. Content Article
    Ahead of the government's medium-term fiscal plan, the annual Institute for Government/Chartered Institute of Public Finance and Accountancy (CIPFA) public services stocktake reveals that public services won’t have returned to pre-pandemic performance by the next election, which in most cases was already worse than when the Conservatives came to power in 2010.  Performance Tracker reviews the state of nine public services – general practice, hospitals, adult social care, children’s social care, neighbourhood services, schools, police, criminal courts and prisons – and their comparative and inter-connected problems.
  7. Content Article
    In this Guardian article, parents reveal their heart-wrenching struggles to access NHS services, which have sometimes been too late to help their children.
  8. News Article
    At least half of integrated care systems (ICS) lack plans for responding to cyberattacks, at a time of increasing cyber risks, HSJ can reveal. The findings also come at a time when the threat posed by cyber attackers is “constantly evolving”, and in the wake of a recent high-profile attack on a supplier to several trusts. In August 2021, NHS England published a framework – What Good Looks Like – to set out what ICSs and member organisations must achieve to be considered digitally mature. Requirements included that all ICSs should have a system-wide plan for “maintaining robust cybersecurity” with “centralised capabilities to provide support across all organisations”. However, 20 ICSs have told HSJ they do not yet have such a cybersecurity strategy or plan in place. Nine ICSs said they did, while the remaining 13 ICSs did not respond. This is despite the NHS being subjected to a growing number of cyber attacks. In 2020-21, NHS Digital reported the health service had been targeted roughly 21 million times on a monthly basis, which marked an increase since before the pandemic. Most of these are malicious emails containing malware and are automatically blocked by cyber defence and monitoring systems. However, in August, a dozen mental health trusts and several NHS 111 and urgent care providers were badly affected by a cyber attack on one of their IT suppliers, Advanced. Several trusts have not yet regained full access to their electronic patient record three months on from the attack. Read full story (paywalled) Source: HSJ, 11 November 2022
  9. News Article
    The number of falls and bed sores recorded in Scotland's hospitals has increased since the Covid pandemic, new data shows. NHS staffing pressures and the deconditioning effect of the Covid lockdown creating more frail patients are being blamed for the rise. The Scottish government paused work on a national prevention strategy for falls when the pandemic started. The strategy has now been shelved and experts argue this is a mistake. Figures released by NHS Healthcare Improvement Scotland (HIS) show that in 2018-19 - the last full year before the Covid pandemic - a total of 26,489 falls were recorded in hospitals. Dawn Skelton, a professor in ageing and health at Glasgow Caledonian University, said there was a "maelstrom" of problems fuelling the increase in hospital falls. She said: "You've got staffing issues definitely but you've also got people who are going in to hospital a step change frailer than they were pre-Covid because of what has happened with all the restrictions. "The people in these falls figures have got no reserves, blow on them and they will fall over, so they are at more risk when they go in." IProf Skelton said it was time to resurrect the Scottish government's falls and fracture prevention strategy as its "value now cannot be underestimated". She added: "Falls and frailty are one of the main causes of long hospital stays and demands on social care and without a spotlight on both the management, but also prevention, the financial and staffing demands on NHS and social care will only rise." Read full story Source: BBC News, 10 November 2022
  10. News Article
    The South East Coast Ambulance Service declared a Critical Incident last night. The NHS Foundation Trust - which serves Kent, Surrey, West Sussex and East Sussex and part of north-eastern Hampshire around Aldershot, Farnborough, Fleet and Yateley - is urging the public to only call 999 in a 'serious emergency'. This is because of IT issues which have resulted in the loss of its Computer Aided Dispatch (CAD) system. In a statement issued on social media at around 9pm, the Ambulance Service said: "We have tonight (10 November) declared a Critical Incident following IT issues which resulted in the loss of our CAD (Computer Aided Dispatch) and the need to move to our back-up telephone systems. "While we are working hard with our IT providers to find a solution to the issue, and have implemented well-rehearsed contingency plans, the loss of the CAD, along with the high demand we are facing across our region tonight, is placing significant pressure on our services. "We continue to answer calls and respond to patients but urge people to only call 999 in the event of a serious emergency and to make use of services, including NHS 111 Online, for help and advice. "We would like to thank our staff and volunteers for their hard work and commitment at this challenging time and assure the public that we are doing everything we can to resolve the issue as quickly as possible." Read full story Source: Kent Live, 10 November 2022
  11. News Article
    NHS bosses are increasingly paying premium rates for agency staff to plug holes in rotas, the BBC has found. Spending in this area rose by 20% last year to hit £3bn in England. For many shifts, bosses have been so short-staffed they have been willing to breach the government pay caps for these agency workers, most of whom are doctors and nurses. Separate data supplied by Labour showed some NHS trusts had paid as much as £2,500 to nurses to fill shifts. Out of 60 responses from trusts, 10 reported the most expensive shift cost over £2,000, and for another 13 it was between £1,000-2,000. The BBC spoke to one cancer doctor who was offered work for £130 an hour - well above the cap for his role - and described the fees available as "astonishing" and a reflection of "desperation by management". Chief executive of Colchester hospital, Nick Hulme, says a combination of factors is playing a role, including the need to open extra wards to cope with rising demand, as well as staffing shortages. Some people are even leaving their jobs, only to return later as agency workers. He says while many agency workers do fantastic work on the wards, he would still prefer to be able to use his own staff. "We know that's best for patient care, best for patient experience. Agency staff require more supervision and tasks such as handovers take longer." Read full story Source: BBC News, 11 November 2022
  12. News Article
    A new report has highlighted for the first time an apparent rise in the suicide rate for pregnant or newly postpartum women in 2020, citing disruption to NHS services due to Covid-19 as a likely cause. According to the review of maternal deaths by MBRRACE-UK, 1.5 women per 100,000 who gave birth died by suicide during pregnancy or in the six weeks following the end of pregnancy in 2020, which is three times the rate of 0.46 per 100,000 between 2017 and 2019. The number of deaths by suicide within six weeks of pregnancy in 2020 was numerically small – 10 women – but this was the same as the total recorded across 2017 to 2019. This is also despite Office for National Statistics figures showing a year-on-year fall in suicides in the population overall in 2020. In relation to the rise in suicides during pregnancy and up to a year after birth, the report states: “During the first year of the covid-19 pandemic, very rapid changes were made to health services… Mental health services were not immune from this and there was a broad spectrum of changes from teams where some staff were redeployed to other roles, through to teams that were able to operate relatively normally… “All of this occurred on a background of a recent huge expansion in specialist perinatal mental health services." Read full story (paywalled) Source: HSJ, 11 November 2022
  13. Content Article
    The MBRRACE-UK collaboration, led from Oxford Population Health's National Perinatal Epidemiology Unit (NPEU), has published the results of their latest UK Confidential Enquiry into Maternal Deaths and Morbidity. These annual rigorous reports are recognised as a gold standard in identifying key improvements needed for maternity services. The latest Saving Lives, Improving Mothers' Care analysis examines in detail the care of all women who died during, or up to one year after, pregnancy between 2018 and 2020 in the UK. This is the first report to include data that demonstrates the impact of the COVID-19 pandemic on maternal deaths.
  14. News Article
    “Failing” IT systems in the NHS are a threat to patient safety. medics have warned. Doctors and nurses should not “tolerate problems with IT infrastructure as the norm”, according to a new editorial, published in The BMJ. Experts from Imperial College London and University College London point to an incident in which IT systems at Guy’s and St Thomas’ NHS Foundation Trust – one of the largest hospital trusts in the country – went down for 10 days. The outage, caused by the July heatwave, led to procedures and appointments being postponed for a number of patients. The new editorial highlights how IT failures can restrict services as doctors are unable to access records and are prevented from ordering diagnostic tests. This can “bring a halt to the everyday business of healthcare”, they said. The authors suggest that the NHS IT infrastructure is “crumbling” and leads to “poor user experiences” as well as patient safety incidents. “Increasing digital transformation means such failures are no longer mere inconvenience but fundamentally affect our ability to deliver safe and effective care – they result in patient harm and increased costs,” they wrote. Read full story Source: 10 November 2022
  15. Content Article
    Earlier this year, information technology (IT) systems at one of the largest hospital trusts in the NHS stopped working for 10 days. This was the latest in a long history of NHS IT system failures across primary and secondary care. As “paperless” is now the default operating mode for many healthcare systems globally, IT failures block access to records, prevent clinicians from ordering investigations, restrict service provision, and bring to a halt the everyday business of healthcare. Increasing digital transformation means such failures are no longer mere inconvenience but fundamentally affect our ability to deliver safe and effective care. They result in patient harm and increased costs. There is a growing disconnect between government messaging promoting a digital future for healthcare (including artificial intelligence) and the lived experience of clinical staff coping daily with ongoing IT problems., writes Joe Zhang and Hutan Ashrafia in a BMJ Editorial. Digital capabilities exist in a strict hierarchy, with IT infrastructure as the foundational layer. This digital future will not materialise without closer attention to crumbling IT infrastructure and poor user experiences. 
  16. News Article
    A new treatment to protect babies against a common and potentially dangerous winter virus has been approved by the Medicines and Healthcare products Regulatory Agency (MHRA). Respiratory syncytial virus (RSV) is the main reason children under five end up in hospital. In a normal winter, RSV mostly causes coughs and colds which clear up in a couple of weeks - but it can be particularly serious in infants under the age of two, causing severe lung problems such as bronchiolitis and pneumonia. Every year, about 29,000 babies need hospital care for RSV and most have no other health issues beforehand. The new antibody treatment, called nirsevimab, from Sanofi and AstraZeneca, has already been shown to reduce lower respiratory tract infections caused by RSV by 74.5% in trials involving 4,000 babies. It works by preventing RSV from fusing to cells in the respiratory tract and causing infections. But it still needs more research in larger numbers of babies before it can be used on the NHS. Researchers now plan to investigate whether it can cut the number of babies needing hospital care for RSV, and are urging parents to sign up to their study. The study is open to newborn babies and those up to 12 months old. Only one visit for the antibody injection is needed, and follow-up sessions happen via an app. Co-study leader Dr Simon Drysdale, consultant paediatrician in infectious diseases at London's St George's Hospital, said the treatment could eventually be given at birth to offer protection for the first months of life, or during routine immunisations at two months old. Read full story Source: 10 November 2022
  17. Content Article
    This is a bite-sized session to give health and care professionals an overview of health disparities and health inequalities - including key evidence, data and signposting to trusted resources to help prevent illness, protect health and promote wellbeing.
  18. News Article
    The number of people in England waiting to start routine hospital treatment has risen to a record high. 7.1 million people were waiting to start treatment at the end of September, according to new figures from NHS England. This is up from 7 million in August, and is the highest number since records begain in August 2007. A staggering 401,537 people have been waiting for more than 52 weeks to start their treatment, according to England’s September figures. NHS medical director Sir Stephen Powis said: “There is no doubt October has been a challenging month for staff who are now facing a tripledemic of Covid, flu and record pressure on emergency services with more people attending A&E or requiring the most urgent ambulance callout than any other October. “Pressure on emergency services remains high as a result of more than 13,000 beds taken up each day by people who no longer need to be in hospital. “But staff have kept their foot on the accelerator to get the backlog down with 18-month waiters down by three-fifths on last year.” Read full story Source: The Independent, 10 November 2022
  19. News Article
    A consultant urologist left a 6.5cm swab in a patient after surgery and failed to identify it in a scan three months later, an inquiry has heard. The public inquiry concerns the work of Aidan O'Brien at the Southern Trust between January 2019 and June 2020. It heard Mr O'Brien endangered or potentially endangered lives by failing to review medical scans. He previously claimed the trust provided an "unsafe" service and was trying to shift blame on to its medics. On Tuesday, the inquiry into Mr O'Brien's clinical practice heard almost 600 patients received "suboptimal care". Counsel for the inquiry Martin Wolfe KC said the 6.5cm swab was left inside a patient by Mr O'Brien during a bladder tumour operation in July 2009. The error was described as a "never event'. At a CT scan appointment three months later in October 2009, a mass inside the patient's body was discovered by the reporting consultant radiologist. While he did not say it was a swab, he did "highlight the abnormality", said Mr Wolfe. A report was sent to Mr O'Brien but, the Inquiry heard, he did not read it and no one took steps to check out the abnormality. Read full story Source: BBC News, 9 November 2022
  20. News Article
    Ministers have offered about 1 million NHS staff in England – everyone bar doctors and dentists – a pay rise of at least £1,400 for 2022-23. That represents a rise of between 4% and 5% for staff covered by the longstanding Agenda for Change negotiating framework. Health unions have rejected the £1,400. They want a rise that would at least match inflation – which is currently 10.1% – while the Royal College of Nursing (RCN) is seeking inflation plus 5%. Without inflation-proof rises, staff will suffer a real-terms cut in their take-home pay, unions say. “Our members will no longer tolerate a financial knife-edge at home and a raw deal at work”, said the RCN general secretary, Pat Cullen. Sara Gorton, head of health at Unison, added: “Inflation has already wiped out this year’s 72p-an-hour increase. The government must put pay right to spare the NHS, its staff and all those relying on its care from a dispute no one wants to see.” The RCN has balloted its members across the UK. The results, published on Wednesday, show that a majority of nurses in most but not all hospitals and other NHS services across the four home nations have rejected the government’s offer and decided to strike in pursuit of better pay. Wes Streeting, the shadow health secretary, has condemned as “unacceptable” the fact that strikes will disrupt services and affect patients’ care. While he has not criticised nurses or any health union, he has blamed ministers for not negotiating with the RCN to try to avert strike action. “I’m concerned, I think lots of people are concerned about the impact of disruption”, he told LBC’s Tonight with Andrew Marr on Monday. “That’s still a disruption to patients, which I think is unacceptable.” If he were the health secretary he would see patients as his “first and foremost” responsibility, he said. “That’s why I think the government have to get a grip on this and get the unions around the table because there is a deal there to be done.” Read full story Source: The Guardian, 9 November 2022
  21. News Article
    Almost one out of every three people infected with HIV through contaminated NHS blood products in the 1970s and 80s was a child, research has found. About 380 children with haemophilia and other blood disorders are now thought to have contracted the virus. The new estimate was produced by the public inquiry into the disaster, after a BBC News report into the scandal. In August, the government agreed to pay survivors and the partners of those who died compensation. The first interim payments of £100,000 per person were made last month. The initial agreement does not cover bereaved parents or the children of those who have died. A wider announcement on compensation is expected when the inquiry concludes, next year. Read full story Source: BBC News, 9 November 2022
  22. News Article
    There has been a sharp rise in long waits for cancer therapy in the past four years, BBC analysis shows. The number waiting more than the 62-day target time for therapy in the past year has topped 67,000 across England, Northern Ireland and Scotland - twice as many as the same period in 2017-18. Waits are also getting worse in Wales, but data does not go that far back. The national cancer director for the NHS in England said staff were striving to catch up on the backlog of care, but experts warned the problems could be putting patients at risk. Steven McIntosh, of Macmillan Cancer Support, told the BBC that the delays were "traumatic" and people were living "day-by-day with fear and anxiety". He said the situation was "unacceptable" and could even be having an impact on the chances of survival. Describing the NHS as "chronically short-staffed", he said: "The NHS doesn't have the staff it needs to diagnose cancer, to deliver surgery and treatment, to provide care, support and rehabilitation." Read full story Source: BBC News, 9 November 2022
  23. News Article
    The only two female ambulance chief executives in the country have said there is something ‘deeply wrong’ with the culture in ambulance services. Helen Ray, the chief executive of the North East Ambulance Service Foundation Trust, said women working in the ambulance service “accept [inappropriate] banter, they accept sexualised behaviour from their male colleagues, and from patients, and they think it is okay”. She stressed “it is absolutely not [okay]” and said women must be given “safe spaces for talking and speaking up about that”. “There is something deeply wrong with the culture in the ambulance service”, she told the NHS Confederation’s Health and Care Women Leaders Network event on Tuesday. Siobhan Melia, interim chief executive of South East Coast Ambulance Service, said when she joined the trust four months ago on secondment from Sussex Community FT, it felt like she had “landed on a different planet”. Ms Melia said it was a culture “not like any other part of the NHS”. “The gender pay gap in my organisation is significant, so we see men in senior roles are taking it upon themselves to abuse their power, [with] both female students and female lower graded staff.” Read full story (paywalled) Source: HSJ, 10 November 2022
  24. Content Article
    Here are five simple tips on how to improve wellbeing and communication by changing how you start and end each day and week positively. Shared by Robin Davis on Twitter.
  25. Content Article
    In this study, Aniza Ismail and Norhani Mazrah Khalid assessed the baseline level and mean score of every domain of patient safety culture among healthcare professionals at a cluster hospital in Malaysia and identifed the determinants associated with patient safety culture. The study found that healthcare professionals at the cluster hospital showed unsatisfactory patient safety culture levels. Most of the respondents appreciated their jobs, despite experiencing dissatisfaction with their working conditions. The priority for changes should involve systematic interventions to focus on patient safety training, address the blame culture, improve communication, exchange information about errors and improve working conditions.
×
×
  • Create New...