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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Call for Concern is a patient safety service for adult inpatients, families and friends to call for help and advice if you or your family are concerned that there is a noticeable change or deterioration in condition. This service is delivered by the Critical Care Outreach team who are available 24 hours a day to help support ward teams in the care of acutely ill patients. We also offer emotional support to patients and their families who have recently been discharged from the Critical Care Unit as this can be an anxious time. When can I call? After you have spoken to the ward team or doctor but feel the healthcare team are not recognising or responding to your concern. If you have been a patient in Critical Care and are experiencing difficulties such as anxiety, bad dreams, low mood or feeling emotional.
  2. Content Article
    Frimley Health has launched a new service for members of the public to independently raise concerns if they believe a patient’s clinical condition is deteriorating. The Call 4 Concern programme enables friends, relatives – and the patients themselves - to make a direct referral if their concerns have not been alleviated by first speaking to the medical team. The Trust’s critical care outreach practitioners will then review the patient, liaise with the medical team and take any appropriate action. At Frimley Park Hospital, call 07717 303231. At Wexham Park Hospital call 07909 930728. The Call 4 Concern programme is available 24 hours a day, seven days a week and has previously been successfully implemented by several other NHS organisations.
  3. Content Article
    Updatable estimates of COVID-19 onset, progression, and trajectories underpin pandemic mitigation efforts. To identify and characterise disease trajectories, Thygesen et al. aimed to define and validate ten COVID-19 phenotypes from nationwide linked electronic health records (EHR) using an extensible framework. Their analyses illustrate the wide spectrum of disease trajectories as shown by differences in incidence, survival, and clinical pathways. The authors have provided a modular analytical framework that can be used to monitor the impact of the pandemic and generate evidence of clinical and policy relevance using multiple EHR sources.
  4. Content Article
    Few things are more devastating than a cancer diagnosis, shares Maria Caulfield, minister for women’s health. She should know – she’s worked on a cancer ward for the best part of twenty five years and supported women through diagnosis, treatment, and recovery. Here, she speaks exclusively to Marie Claire UK about her ten year plan and how we can make gynae issues a thing of the past. Not only does she want to prevent the five gynaecological cancers, but she wants to help make sure we diagnose them early, too: we know that the earlier you are diagnosed, the higher your chance of survival.
  5. Content Article
    Shared decision making and regular communication throughout a patient’s surgery pathway would, a recent HSJ webinar argued, help the NHS move from the concept of waiting lists to one of preparation lists – and to a better way of dealing with the backlog. Claire Read reports.
  6. Content Article
    Through the National Joint Registry (NJR) Surgeon and Hospital Profile service you can find information about: Consultant surgeons who carry out hip, knee, ankle, elbow and shoulder joint replacement surgery in England, Wales, Northern Ireland, the Isle of Man and Guernsey. Hospitals where those joint replacement operations are carried out. For each consultant surgeon listed, you will find information about their practice including how many hip, knee, ankle, elbow or shoulder procedures they have carried out since 2018. For hip and knee consultant surgeons, there is also information about mortality in the first 90-days after surgery. For hip surgeons only, there is information about the use of ODEP-rated implants as a proportion of total practice.
  7. Content Article
    This tool is easy to use and will help you better understand your own risks and benefits of having hip or knee joint replacement surgery. It has been designed using the National Joint Registry (NJR) information from people just like you who have chosen to have their procedure outcome details recorded on the registry. You may wish to take a printout of your results to use in your medical consultation.
  8. Content Article
    Royal Philips, a global leader in health technology, has published their Future Health Index (FHI) 2022 report: ‘Healthcare hits reset: Priorities shift as healthcare leaders navigate a changed world’. Now in its seventh year, the Future Health Index 2022 report, based on proprietary research from almost 3,000 respondents conducted across 15 countries, explores how healthcare leaders are harnessing the power of data and digital technology as they look to address their key challenges coming out of the pandemic. The 2022 report paints a picture of a sector that is radically re-evaluating priorities as it strives to deliver improved patient care. “As we emerge from the pandemic, healthcare leaders worldwide are embarking on a reboot,” said Jan Kimpen, Chief Medical Officer, Philips. “Many are refocusing on both new and existing priorities, from addressing staff shortages and extending care delivery, to leveraging big data and predictive analytics.”
  9. Content Article
    People taking ownership of their health journey is hardly news. Long gone are the days when patients were passive players in their health experience. Today, technology engages, motivates, and empowers people to take control. Engaged patients are more likely to listen to preventive guidance, ask questions, and seek further information. The benefits for these patients—and for healthcare systems—are immense: improved health outcomes, reduced costs, and better care experiences for both patients and clinicians. But what role have such engaged patients played in transforming healthcare? And why is this important for the future? Kristin Molina, business leader for Philips Enterprise Care Collaboration, discusses this in an article for Patient Safety and Quality Healthcare (PSQH).
  10. News Article
    Women are wasting their time and money buying do-at-home menopause testing kits, doctors have warned. The urine tests are not predictive enough to tell whether a woman is going through the phase when her periods will stop, doctors have told the BBC. The tests, which give a result within minutes, accurately measure levels of follicle-stimulating hormone (FSH), which helps manage the menstrual cycle. But experts say it is not a reliable marker of the menopause or perimenopause. Dr Annice Mukherjee, a leading menopause and hormone doctor from the Society of Endocrinology, told the BBC the FSH urine tests were “another example of exploitation of midlife women by the commercial menopause industry, who have financial conflicts of interest”. “It’s not helpful for women to access [FSH] directly,” she said. “It is not a reliable marker of perimenopause and can cause more confusion among women taking the test. At worst, misinterpretation of results can cause harm.” The Royal College of Obstetricians and Gynaecologists (RCOG), along with other leading experts in women’s health, said the tests could be unhelpful and potentially misleading. Read full story Source: The Guardian, 10 June 2022
  11. Content Article
    This study by Sir Robert Francis QC looks at options for a framework for compensation for the victims of the infected blood tragedy.   Sir Robert will give evidence about his work to the Infected Blood Inquiry in July.  Before then, it is important that the Inquiry, and recognised legal representatives of its infected and affected core participants, have an opportunity to consider his work.
  12. Content Article
    According to patient safety campaigners, hundreds of women have been forced to endure “barbaric” pain while undergoing hysteroscopy tests after being denied pain relief options and anaesthetists were not available. HSJ recently reported that campaigners have identified at least 240 women who underwent the procedure without being told they were entitled to a general anaesthetic to manage the pain of the invasive test and we have seen similar stories on the hub community forum on the topic. Guidance for doctors says pain relief should always be discussed. Instead, these women were found to be underinformed about their own rights and expected to simply endure what can be an incredibly painful process of internal investigation. Just because some women report only minimal or no discomfort, that does not mean this is a painless procedure; for those who do suffer, the experience can be very traumatic. To say these women did not need and could not be provided with a choice of anaesthetic or other analgesic is a form of medical gaslighting, writes Hannah Fearn in this article for the Independent.
  13. News Article
    Coordination of waiting lists and elective treatment across health systems and regions should be ‘far more systematic’, and could have happened earlier, chief executives of some of the hardest hit trusts have told HSJ. In interviews for the HSJ Health Check podcast, the CEOs of King’s, Croydon, Chester and Sandwell and West Birmingham hospital trusts spoke about their experience in the pandemic and what could be learned from it. These included the need for faster decision making; resources for deprived and diverse areas, which are often hardest hit; the need for basic staff facilities such as parking and eating areas for staff; longer-term attention to the wellbeing of staff who were most affected; and to give time for trusts to recover. On elective care, the CEOs highlighted how the length of lists and waits, and the NHS’s ability to keep up, are now much worse in some areas than others. Some of those with the longest waits and lists at present – such as Countess of Chester and Birmingham – were also heavily hit by Covid; for others this is not the case. There were moves, particularly later in the pandemic, for patients who were on the elective waiting list of one trust to be treated at another, for example if they needed urgent treatment and faced harm if delayed, while other hospitals were still able to treat less urgent cases. Combining lists, often known as “shared patient tracking (or treatment) lists”, could also mean capacity being managed more efficiently across providers. Read full story (paywalled) Source: HSJ, 10 June 2022 .
  14. News Article
    Pharmacists and some other healthcare professionals, rather than just GPs, will soon be able to sign people off sick from work, under new rules. The law change will take effect in July and apply across England, Wales and Scotland. The aim is to free up family doctors' time. People off work for more than seven consecutive days because of illness may need to show a note from a healthcare professional to their employer. When the new legislation is passed, nurses, occupational therapists, pharmacists (working in hospitals and GP practices) and physiotherapists will be able to provide the notes, in addition to GPs. Health and Social Care Secretary Sajid Javid said: "I know how important it is for people to be able to see their GP speedily and in the way they want. "That's why we are slashing bureaucracy to reduce GPs workloads, so they can focus on seeing patients and giving people the care they urgently need. Read full story Source: BBC News, 9 June 2022
  15. News Article
    Rises in the cost of living are already having a negative impact of people's health, health professionals warn. BBC News has been told of people skipping meals or cutting back on medication, because of money worries. The Royal College of Nursing says people are having to make heart-wrenching choices that compromise their health and wellbeing. Along with GPs and hospital doctors, they warn health inequalities between rich and poor risk becoming worse. Laura Brant, 28, has already had to make some tough choices about a treatment keeping her alive. Having lived with kidney disease since the age of seven, she has already had two kidney transplants - and now needs another. Laura is dependent on a dialysis machine to carry out the filtering process usually performed by the kidneys. Without it, she could be dead in a week. Laura was having dialysis at home - but the machine used so much electricity and water the bills started to mount rapidly. "I'd say that it's the straw that broke the camel's back, really, with the cost of running the dialysis machine, the water it uses, the electric," she says. "And it was adding to my anxiety, like, 'How am I going to pay to do this treatment every month?'" Royal College of Physicians president Dr Andrew Goddard says some of his respiratory-medicine colleagues are hearing of patients choosing to turn off oxygen supplies to save money. "Respiratory disease disproportionately affects those least able to afford to improve their social circumstances," he says. "It seems likely the cost of living crisis will widen this disparity further." Read full story Source: BBC News, 9 June 2022
  16. Content Article
    The variety of alarms from all types of medical devices has increased from 6 to 40 in the last three decades, with today’s most critically ill patients experiencing as many as 45 alarms per hour. Alarm fatigue has been identified as a critical safety issue for clinical staff that can lead to potentially dangerous delays or non-response to actionable alarms, resulting in serious patient injury and death. To date, most research on medical device alarms has focused on the nonactionable alarms of physiological monitoring devices. While there have been some reports in the literature related to drug library alerts during the infusion pump programming sequence, research related to the types and frequencies of actionable infusion pump alarms remains largely unexplored.
  17. News Article
    A troubled NHS trust failed for months to give vital medication to a prison inmate who had a long-standing diagnosis of HIV, an inquest has found. A jury at Essex Coroner’s Court concluded that a series of failures and neglect by Essex Partnership University Trust (EPUT) contributed to the death of Thokozani Shiri in April 2019. The 21-year-old spent two spells as a prisoner at HMP Chelmsford, where EPUT provided some services at the time. He was considered vulnerable due to a long-standing diagnosis of HIV for which he was receiving treatment before he went to prison, and the trust was aware he had HIV throughout both stays, the inquest heard. The inquest jury identified that five separate failings had “probably caused” Mr Shiri’s death. These included: a failure to provide antiretroviral medication to Mr Shiri during both periods of imprisonment; a failure to refer him to an HIV clinic; the absence of an appropriate care plan and engagement with a multidisciplinary team; and inadequate management of records. Each failing on behalf of the trust was considered by the jury to have amounted to neglect. Read full story (paywalled) Source: HSJ, 9 June 2022
  18. Content Article
    The current hospital backlog has had a huge impact on many patients waiting for treatment. But if you are a woman, on a low income or from an ethnic minority background, you are more likely to have a worse experience of waiting for care. Research from Healthwatch has highlighted people were unhappy with the communications they received and the lack of support the NHS gave them to help with things like pain relief or accessing physiotherapy. These concerns were not experienced equally by all, and findings were particularly stark among disabled people, those with long term health conditions, and those on lower incomes.    A new poll of 1,000 adults on NHS waiting lists shows that a poorer experience of waiting can be linked to factors such as wealth, disability, level of education, gender or ethnicity.
  19. News Article
    Women, low earners and ethnic minorities are faring worse on NHS waiting lists, according to research. Healthwatch, a patient watchdog, warned there was a risk that those with “more demands on their lives” such as long hours or caring responsibilities could end up at the back of the queue. It urged hospitals to be proactive in managing waiting lists and communicate with patients who might otherwise be left in limbo. The Healthwatch survey found 54% of women had waited more than four months for treatment, compared with 42% of men. They were also more likely to have had treatment delayed or cancelled, and to feel that a delay to treatment had made an impact on their ability to work. Some 54% of people on lower incomes had been waiting more than four months for hospital care, compared with 34% of higher wealth individuals. They reported a greater impact on their mental health and their ability to work. And 57% of respondents from ethnic minorities had faced a delay to or cancellation of hospital treatment, compared with 42 per cent of white British people. Louise Ansari, Healthwatch England’s national director, said the factors could have a “layering effect” that meant people had a much poorer experience, calling for “an additional specific focus on those groups” so that they do not end up “in worse and worse health”. Read full story (paywalled) Source: The Times, 8 June 2022
  20. Content Article
    Dr Gordon Hay, service director of A&E/urgent care services at Moorfields Eye Hospital discusses with Digital Health the challenge to minimising hospital visits during the pandemic and how Moorfields Eye Hospital utilised a video conference platform to implement a fully functional virtual A&E service, providing an effective hybrid care delivery model for the future.
  21. Content Article
    The Messenger review may be full of well-meaning and often well-judged sentiments – but the recommendations were either peripheral (a five-day course for middle managers) or so vague as to be virtually worthless (proposals to make equality, diversity and inclusion everyone’s business). Lord Rose, Sir Ron Kerr, Tom Kark and indeed Sir Robert Francis all made similar recommendations about ensuring the quality of NHS leadership, but the Messenger review has a slightly different thrust. It aimed to review health and social care leadership. By this measure, the review has failed to do what it set out to achieve. Social care and indeed primary care are an afterthought, with the focus on the acute sector, writes Alastair McLellan and Annabelle Collins for the HSJ.
  22. News Article
    Sajid Javid’s claim that the number of NHS roles dedicated to promoting equality and diversity should be cut is incorrect and not what the government-commissioned review into NHS management recommended, according to its author. The review by General Sir Gordon Messenger and Leeds Teaching Hospital chair Dame Linda Pollard was published Wednesday. Speaking to the Daily Telegraph on Tuesday evening, the health secretary said: “In my view, there are already too many working in roles focused solely on diversity and inclusion, and at a time when our constituents are facing real pressures around cost of living, we must spend every penny on patients’ priorities. “As this report sets out, it should be the responsibility of everyone to encourage fairness and equality of opportunity which is why we must reduce the number of these roles.” Speaking later to HSJ, Mr Javid was asked if there was any area of NHS management cuts should be made. He said: “I would like to see fewer managers in terms of diversity managers and things, because I think it should actually be done by all management and all leadership, and not contracted out as some kind of tick-box exercise.” However, when HSJ spoke to General Messenger he said: “The report does not recommend the reduction of EDI (equality, diversity and inclusion) professionals. “What it does say though, is that if one successfully inculcates equality, diversity and inclusion to every leadership’s responsibilities then that becomes an accepted, instinctive, understood part of being a leader and a manager at every level then the requirement for dedicated EDI professionals should reduce over time." Read full story (paywalled) Source: HSJ, 8 June 2022
  23. News Article
    A number of hospitals are insisting that patients keep wearing masks despite instructions from NHS chiefs to drop the rules. National coronavirus guidance which insisted on face coverings has now been scrapped, with health officials leaving it to local organisations to draft their own policies. However, several hospitals have called on patients and staff to continue to wear masks and face coverings on their sites. Sajid Javid, the Health Secretary, has repeatedly called on NHS trusts to drop restrictions in hospitals which are limiting operational capacity. Last month, he threatened to name and shame hospitals that do not lift social distancing measures and restrictions on visitors. A letter from health chiefs said that patients visiting accident and emergency (A&E) departments, hospital outpatient appointments and GP surgeries no longer needed to wear masks “unless this is a personal preference”. Hospitals have now begun issuing guidance for their local communities, with a number saying they intend to keep insisting on people wearing masks. The Sheffield Teaching Hospitals NHS trust issued a notice to patients and staff saying: “We are still asking patients, visitors, staff and anyone working at one of our hospital or community sites to continue to wear a mask, gel hands and social distance while in our buildings despite the lifting of national restrictions." “This is to keep vulnerable people as safe as possible.” Read full story (paywalled) Source: The Telegraph, 8 June 2022
  24. News Article
    Concerned healthcare workers in Illinois and Indiana are calling on The Joint Commission to add a safe staffing standard to its accreditation process. Yolanda Stewart, a patient care technician at Northwestern Memorial Hospital, once injured her back so badly on the job that she couldn’t work for six months. But when she talks about that time, she doesn’t mention her own pain. Instead, she talks about the patient she’d been trying to help, recalling his extreme discomfort. Because the unit was short-staffed, Stewart lifted and turned the patient on her own. The move helped the patient but cost Stewart. Many healthcare workers have similar stories, she says, adding, “Working short-staffed is a safety issue for workers and patients.” In fact, reports show that lack of staff in hospitals leads to higher patient infection and death rates. Covid-19 has greatly worsened the healthcare staffing shortage, with 1 in 5 hospital employees — from environmental services workers to nurses — leaving the field. Hospitals have grappled with staffing issues since before the pandemic, but Covid-19 highlighted the challenges — and exacerbated them. Now, concerned healthcare workers throughout Illinois and Indiana are sounding the alarm. They’re calling on The Joint Commission — the third-party agency that accredits 22,000 US healthcare organisations — to add a safe staffing standard to its accreditation process, similar to student-to-teacher ratio requirements that many states have. “We have all kinds of rules to make sure that hospitals are safe: We make sure that healthcare workers wash their hands before procedures, that they wear gloves and protective equipment, that bed sheets are changed between patients. Yet there are no statewide regulations about hospital staffing levels,” said Service Employees International Union (SEIU) Healthcare Illinois President Greg Kelley at a demonstration in early June. Read full story Source: Chicago Health, 8 June 2022
  25. News Article
    Nursing leaders are to write to Northern Ireland's Secretary of State Brandon Lewis over the failure to establish an Executive and the risk this poses to patients. The Royal College of Nursing (RCN) congress has passed a motion calling for all political parties and the UK Government to commit to the immediate formation of a fully functioning Executive and Assembly. Fiona Devlin, chair of the RCN Northern Ireland board, brought the matter to the congress and said the move represents the deep level of concern in the profession. “There is a responsibility to speak up when patients are coming to harm,” she said. “The health service is about to completely tip over the edge. We felt we did everything we could to communicate our concerns before the elections, and since then, nothing has changed. “The system is crumbling minute by minute, we have the worst waiting lists in the UK, our emergency departments are completely overstretched, primary care and the independent sector are in crisis. “Patients can’t be decanted out of ambulances into emergency departments because there’s no room in the hospitals and they’re dying in the back of ambulances. Read full story Source: Belfast Times, 8 June 2022
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