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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Basic psychosocial support skills are important for any intervention and key to maintaining and promoting the health of all communities. Such skills are also essential for many involved in the COVID-19 response as well as other frontline workers, whether they identify as a mental healthcare provider or not. This guide can be helpful for all frontline workers responding to COVID-19.
  2. Content Article
    Every year, thousands of emergency department (ED) visits result in patients being discharged with oral antibiotic prescriptions. Published studies that assess the appropriateness of these antibiotic regimens are limited. The purpose of this study from Bauman et al. was to examine the appropriateness of antibiotic prescriptions written for patients discharged from a community hospital’s ED. A total of 76% of the prescribed antibiotics were appropriate, 16% were inappropriate, and the remaining 8% were not assessable. Duration was the most common reason for a regimen to not be optimal. The most frequently inappropriately prescribed antibiotics included cephalexin (but it is noted cephalexin was included in almost half of the antibiotic regimens in this study), clindamycin, and azithromycin. Infections that were most frequently treated inappropriately were skin and soft tissue infections, dental infections, and sinusitis. 
  3. Content Article
    Lisa Drake, an NHS ex General Practice Manager now working in a digital advisory role, shares some of the missed opportunities for digital ways of working she witnessed when she was a patient herself.
  4. News Article
    It was hailed as a cutting-edge laboratory that would play a key role in response to Covid-19 and future epidemics, carrying out 300,000 tests a day. Announcing the project in November 2020, then-health secretary Matt Hancock said the project “confirms the UK as a world leader in diagnostics”. But less than 18 months later, the Rosalind Franklin Laboratory – named in honour of the renowned British scientist – has been plagued by failure while costing almost twice as much as its initial £588m budget, The Independent understands. Instead of being at the forefront of the fight against Covid, the project opened six months late, facing a string of issues with equipment, staff and construction, with barely 20% of its touted capacity being reached. Now, as the government winds down its “lighthouse” testing labs as part of the plan to “live with Covid”, leaving the Leamington Spa facility as the last lab standing, there are questions about the future of the site – and whether it would be able to cope with the nation’s testing needs alone if another deadly wave of Covid were to emerge. Read full story Source: The Independent, 28 April 2022
  5. Content Article
    The impact of COVID-19 on mortality can be broadly split into three categories: direct impacts; indirect impacts; and wider social and economic impacts. Indirect impacts represent excess deaths due to stresses on the health system or changes in the health-seeking behaviour of individuals. These are the focus of this bulletin from the COVID-19 Actuaries Response Group. At this stage of the pandemic, the mortality impacts are shifting from direct to indirect. Analysing emerging data can help to identify the magnitude of these impacts and the extent to which they are asymmetric across the population. If care pathways do not rapidly return to pre-pandemic levels, then the COVID-19 pandemic will affect the standard of healthcare, morbidity and mortality across the UK for years to come.
  6. Content Article
    SARS-CoV-2 infection can damage many organs other than the lungs. The most troubling is damage to the brain. A series of recent studies document long term brain-damage in as many as one quarter of all those infected regardless of the severity of the initial disease. Those numbers are daunting considering that an estimated 140 million Americans have been infected by SARS-CoV-2. Symptoms, such as brain fog, fatigue, depression and a host of other maladies, may be mild or incapacitating. Several studies warn that treatment of those with long term brain injury will strain the healthcare care system for years to come. Understanding the origin and treatment of Covid-19 related brain injury is a high priority for medical science.
  7. Event
    Part of the ongoing series of monthly webinars on WHO Global Patient Safety Challenge: Medication Without Harm. Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. WHO Patient Safety Flagship has initiated a series of monthly webinars on the topic of “WHO Global Patient Safety Challenge: Medication Without Harm”,. The main objective of the webinar series is support implementation of this WHO Global Patient Safety Challenge: Medication Without Harm at the country level. Considering the huge burden of medication-related harm, Medication Safety has also been selected as the theme for World Patient Safety Day 2022. In the context of medication safety, high-risk situations relate to those circumstances associated with a significant risk of medication-related harm, such as situations arising from look-alike, sound-alike (LASA) medications and high-alert medications. High-risk situations could be triggered by one or more of the following broad factors: medication, provider and patient, and systems factors (work environment). Organisations need to prospectively design and implement strategies to identify high-risk situations related to medications and build a robust system that intercepts them before they result in patient harm. At this webinar, WHO will present the WHO technical report on “Medication Safety in High-risk Situations” and experiences from different countries and organizations will be shared on how to address high-risk situations and reduce the risk of medication-related harm. Register
  8. News Article
    The United States could see a deficit of 200,000 to 450,000 registered nurses available for direct patient care by 2025, a 10 to 20% gap that places great demand on the nurse graduate pipeline over the next three years. The new estimates and analysis come from a McKinsey report published this week. The shortfall range of 200,000 to 450,000 holds if there are no changes in current care delivery models. The consulting firm estimates that for every 1% of nurses who leave direct patient care, the shortage worsens by about 30,000 nurses. To make up for the 10 to 20%, the United States would need to more than double the number of new graduates entering and staying in the nursing workforce every year for the next three years straight. For this to occur, the number of nurse educators would also need to increase. "Even if there was a huge increase in high school or college students seeking nursing careers, they would likely run into a block: There are not enough spots in nursing schools, and there are not enough educators, clinical rotation spots or mentors for the next generation of nurses," the analysis states. "Progress may depend on creating attractive situations for nurse educators, a role traditionally plagued with shortages." Read full story Source: Becker's Hospital Review, 12 May 2022
  9. Content Article
    Analysis suggests potential instability and workforce gaps in the US healthcare sector. A call to action for all stakeholders could help. COVID-19 has altered many US nurses’ career plans. Over the past two years, McKinsey has found that nurses consistently, and increasingly, report planning to leave the workforce at higher rates compared with the past decade. Even as COVID-19 cases fluctuate, US healthcare providers are still experiencing the workforce and operational challenges exacerbated by the pandemic. Patient demand is expected to rise, given the growing and aging population of the United States. Without addressing this potentially wider divide between patient demand and the clinical workforce, with a specific focus on nurses, the US health sector could face substantial repercussions. If no actions are taken, there will likely be more patients in the United States who will need care than nurses available to deliver it. This report from McKinsey& Company provides context for how COVID-19 changed the nursing workforce, the long-term implications for nurses and healthcare stakeholders, and actions to consider to increase the odds of closing the gap. In the last section, it highlights how healthcare providers, federal and state governments, the private sector, the nursing workforce, and broader society could encourage those who are training to be nurses.
  10. Content Article
    The Patient Safety Movement's World Patient Safety, Science & Technology Summit took place on the 29-30 April. For those of you who were unable to attend, the entire event is now available on YouTube and is accessible to anyone using the link below.
  11. News Article
    Nurses from across the country are heading to Washington, D.C., and Nashville, Tenn., this week to march for better working conditions and to show support for nurse RaDonda Vaught. Ms. Vaught, 38, was convicted of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 after overriding an electronic medical cabinet as a nurse at Vanderbilt University Medical Center in Nashville. Her case has spurred a national outcry from nurses who argue the ruling sets a dangerous precedent for the profession and will discourage nurses from speaking up about errors. Ms. Vaught's sentencing is scheduled for 13 May in Nashville, and she faces up to eight years in prison. Hundreds of nurses are planning to march in Nashville the day of the hearing to show their support for Ms. Vaught and to fight for better protection for nurses against criminal prosecution of errors. "We expect a large number of people to show up … just to show our strength in numbers and hope that the judge takes this into consideration and makes it slightly better by not sentencing her to any prison time," said Erica, a Las Vegas-based hospice nurse who is attending the sentencing. Read full story Source: Becker's Hospital Review, 13 May 2022
  12. News Article
    The NHS has recorded its largest monthly increase in the waiting list for 10 months, as unprecedented challenges in urgent and emergency care continue to disrupt recovery. The elective figures published today for March presented mixed results, but much of the good news – a drop in the number of two-year waiters – had already been announced by NHS England in unvalidated figures for April. Meanwhile, the system recorded its largest monthly rise in the overall list for 10 months, with the number of patients growing by 174,847 to hit a new record 6.36 million. This is the biggest month-on-month increase since the number jumped between April and May 2021 when it rose by 181,708 to hit 5.3 million. The overall list has risen every month since May 2021, but the rises in the last four months have all been under 80,000. The NHS warned in February it expects the waiting list to continue rising until March 2024, with patients now seeking care after various covid lockdowns. Meanwhile, the number of patients waiting 12 hours from a decision to admit in accident and emergency departments reached a new high in data published today, covering April. Ambulance response times also improved slightly last month from March’s all-time low. Average category one performance – for immediately life-threatening conditions, such as cardiac or respiratory arrest - was 9:02 minutes against a seven-minute target, but still an improvement on last month’s 9:35 minutes. Read full story (paywalled) Source: HSJ, 12 May 2022
  13. News Article
    A former medical director on the Isle of Man, who lost her job when she questioned decisions made on the island during the COVID-19 pandemic, has won her case for unfair dismissal at an employment tribunal. The hearing, which began in January, heard how Dr Rosalind Ranson was victimised and dismissed from her role after making 'protected disclosures' as part of her efforts to persuade the Manx Government to deviate from Public Health England (PHE) advice in the early stages of the pandemic. Dr Ranson, who had extensive experience as a GP and as a senior medical leader in the NHS in England, was appointed to her post as the island's most senior doctor in January 2020 with the aim of tackling what she identified as a disillusioned medical workforce, failings in management, and a bullying culture. She was soon called on to provide expert medical advice and guidance on how the Isle of Man’s health system should respond to the spread of COVID-19. In March, Dr Ranson channelled concerns from the island's doctors that the advice from PHE was flawed, and that a more robust approach should be taken to stem the spread of SARS-CoV-2. That included closing the island’s borders – a move that was initially ignored. Dr Ranson became concerned that her medical advice was not being heeded and that it might not be being passed on to ministers by the then Chief Executive of the Isle of Man’s Department of Health and Social Care (DHSC), Kathryn Magson, who was not medically qualified. The tribunal heard that because Dr Ranson had "blown the whistle" when she spoke out, she was sidelined and eventually dismissed unfairly. Read full story Source: Medscape, 11 May 2022
  14. News Article
    More than 107,000 Americans died of drug overdoses last year, setting another tragic record in the nation’s escalating overdose epidemic, the Centers for Disease Control and Prevention (CDC) estimated Wednesday. The provisional 2021 total translates to roughly one U.S. overdose death every 5 minutes. It marked a 15% increase from the previous record, set the year before. The CDC reviews death certificates and then makes an estimate to account for delayed and incomplete reporting. Dr. Nora Volkow, director of the National Institute on Drug Abuse, called the latest numbers “truly staggering.” The White House issued a statement calling the accelerating pace of overdose deaths “unacceptable” and promoting its recently announced national drug control strategy. It calls for measures like connecting more people to treatment, disrupting drug trafficking and expanding access to the overdose-reversing medication naloxone. Experts say the COVID-19 pandemic has exacerbated the problem as lockdowns and other restrictions isolated those with drug addictions and made treatment harder to get. Read full story Source: AP News, 11 May 2022
  15. Content Article
    Last week a think-tank report drew newspaper headlines with the claim that the NHS ranked second from bottom across "a series of major health outcomes" compared with other international systems. Does the NHS really perform so badly internationally, and is there a real problem with our health outcomes? Mark Dayan looks at the evidence.
  16. Event
    Webinar to report on progress with updating the ISO 23908 standard on safety mechanisms in the design and manufacture of devices and the prevention of sharps injuries. See the agenda below. Agenda for webinar on 22.06.22 at 09.00 updating the ISO 23908 standard on safety mechanisms and the prevention of sharps injuries.docx Click here to join the meeting
  17. Content Article
    With the ongoing COVID-19 pandemic, growing evidence shows that a considerable proportion of people who have recovered from COVID-19 have long-term effects on multiple organs and systems. A few longitudinal studies have reported on the persistent health effects of COVID-19, but the follow-up was limited to 1 year after acute infection. The aim of this study from Huang et al., published in Lancet Respiratory Medicine, was to characterise the longitudinal evolution of health outcomes in hospital survivors with different initial disease severity throughout 2 years after acute COVID-19 infection and to determine their recovery status. The study found thategardless of initial disease severity, COVID-19 survivors had longitudinal improvements in physical and mental health, with most returning to their original work within 2 years; however, the burden of symptomatic sequelae remained fairly high. COVID-19 survivors had a remarkably lower health status than the general population at 2 years. The study findings indicate that there is an urgent need to explore the pathogenesis of long COVID and develop effective interventions to reduce the risk of long COVID.
  18. News Article
    The scope of the UK public inquiry into the handling of the Covid pandemic has widened to include a focus on children. When the draft terms were published in March, there was criticism that they failed to even mention the impact on children and young people. But after a public consultation, the final terms have been published and now incorporate the effect on the health, wellbeing and education of children. The final terms of reference were decided following a four-week public consultation on the draft terms. As well as expanding the terms to include the impact on the health, wellbeing and education of children and young people, the inquiry will also look at the wider mental health impact across the population. The focus on inequalities will also be strengthened, the inquiry said, so that the unequal impact on different sections of society will be considered at all stages. Alongside these issues, the UK-wide inquiry will also look at the following issues which were included originally: the UK's preparedness for the pandemic the use of lockdowns and other "non-pharmaceutical" interventions, such as social distancing and the use of face coverings the management of the pandemic in hospitals and care homes the procurement and provision of equipment like personal protective equipment and ventilators support for businesses and jobs, including the furlough scheme, as well as benefits and sick pay. Read full story Source: BBC News, 12 May 2022
  19. News Article
    The Government is considering setting a tougher cancer diagnostic target as part of its declared ‘war on cancer’, HSJ has been told. Sajid Javid announced a “war on cancer” and launched a call for evidence on what could be done to improve services in February. HSJ understands one of the measures being considered is increasing the existing target for cancer diagnosis, set in the 2019 NHS long-term plan. The current target committed the service to diagnosing 75% of cancers at stages one and two by 2028. At present, performance is around 54% and late stage diagnosis is a key factor behind the UK’s poor performance on cancer mortality, compared with other wealthy nations. Cancer Research UK has asked for government, as part of the latest consultation, to set a target of at most 20% diagnosed at stage three and four – effectively, 80% or more at stages one and two – by 2032. The Royal College of Radiologists pointed out in February that there was a shortfall of nearly 2,000 consultant radiologists and 20% fewer consultant oncologists to meet the existing gaps. Read full story (paywalled) Source: HSJ, 13 May 2022
  20. News Article
    A trade union has written to every politician representing the Scottish Borders to highlight "dangerous staffing levels" in local hospitals. Unison claims serious breaches of safety guidelines are occurring daily due to a lack of nurses, auxiliaries and porters. The letter says staff are unable to take proper rest breaks or log serious incidents in the reporting system. NHS Borders said patient and staff safety was its number one priority. Unison said working conditions in the area were regularly in breach of regulations. Greig Kelbie, the union's regional officer in the Borders, said: "We are getting regular messages from our members to tell us about the pressure they are under - and that they can't cope. "The care system was under pressure before Covid, but the pandemic has exasperated the situation, particularly at NHS Borders. "The NHS has been stretched to its limits and it is now at the stage where it is dangerous for patients and staff - we're often told about serious breaches of health and safety, particularly at Borders General Hospital where there are issues with flooring and staff falling. "We work collaboratively with NHS Borders to do what we can, but we also wanted to make politicians aware of how bad things have become. "We need our politicians to step up and implement change - we want them to make sure the Health and Care Act is brought to the fore and that it protects our members." Read full story Source: BBC News, 13 May 2022
  21. News Article
    Children’s lives are being put at risk, charities warn, as waiting times for eating disorder services soar to record highs. The number of children waiting more than four months following an urgent referral for an eating disorder was more than seven times higher at the end of 2021-22 compared to the same period in the previous year. Data showed that at the end of quarter four of 2021-22, 94 children were waiting more than 12 weeks following an urgent referral, the highest on record, compared to just 13 at the end of 2020-21. The latest NHS data on waiting times for community eating disorder services for children also showed more than 1,900 children were waiting for treatment at the end of March. Of these, 24 were waiting to start urgent treatment - up from 130 last year. Sophie Corlett, director of external affairs at Mind, said: “Our government is shamefully failing children and young people with eating disorders at the time when they need help most. Eating disorders have one of the highest mortality rates of any mental health problem. Children in need of urgent NHS treatment for eating disorders should always be seen within one week yet some children are still waiting for treatment after twelve weeks. This is irresponsible and disgraceful.” Read full story Source: The Independent, 12 May 2022
  22. Content Article
    In 2010, the US Department of Health and Human Services Office of Inspector General (OIG) reported the first national incidence rate of patient harm events in hospitals—27% of hospitalised Medicare patients experienced harm in October 2008. During that month, hospital care associated with these events cost Medicare and patients an estimated $324 million in reimbursement, coinsurance, and deductible payments. Nearly half of these events were preventable. OIG conducted a new study to update the national incidence rate of patient harm events among hospitalised Medicare patients in October 2018. This work included calculating a new rate of preventable events and updating the cost of patient harm to the Medicare programme.
  23. News Article
    A recent report based on research and case studies of good practice in combatting digital health inequalities demonstrates the importance in working with patients who are digitally excluded. The report, Putting patients first: championing good practice in combatting digital health inequalities, is the second report by the Patient Coalition for AI, Data and Digital Tech in Health. This report focuses on digital health inequalities and the impact that digital exclusion is having on health in the UK. It highlights different reasons for disparities in a person’s ability to access and use digital health technology and provides insights into the severity of the UK’s digital inequalities. The Coalition report concludes recommending that the Government and NHS should: Engage with those digitally excluded Ensure patients have a choice Ensure the language is appropriate for all audiences Learn from good practice. Read full story Source: The Patients Association, 9 May 2022
  24. Gallery Image
    Midazolam and Metoclopramide injections
    Two very different drugs with similar packaging and labelling.
  25. Content Article
    The formation of Integrated Care Systems (ICS) as part of the Government’s plan to integrate health and social care ought to be an opportunity for a once-in-a-generation improvement in the quality of social care provision. For too long the social care sector has been in crisis due to increasing demands on the system which have not been met with enough funding or a sensible organisational structure.  Integration, if done properly, would alleviate many of the current problems and result in a better care experience for those who need care. However if integration is mishandled the Government will miss this unique opportunity and the crisis will continue, and indeed probably become more acute.
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