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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The WHO's Global Patient Safety Action Plan aims to provide a strategic direction for concrete actions to be taken by countries, partner organisations, care facilities and World Health Organization (WHO). It sets out a vision of a “world in which no patient is harmed in healthcare, and everyone receives safe and respectful care, every time, everywhere” and a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care.
  2. Content Article
    The aim of this study was to derive a comprehensive list of nursing-sensitive patient outcomes (NSPOs) from published research on nurse staffing levels and from expert opinion. The authors identified strong evidence for a significant association between nurse staffing levels and NSPOs. The results may guide researchers in selecting NSPOs they might wish to prioritise in future studies.
  3. News Article
    Dozens of acute trusts have operated at very high levels of bed occupancy in the past month, as they deal with a surge in non-covid patients with thousands fewer beds than normal. At one point in May, 49 general acute trusts out of 145 — the most since before covid — operated at occupancy of 95 per cent or more in adult acute beds. Up to eight trusts at a time were operating at 99 or 100% occupancy during May, according to analysis of published data. NHS England, prior to covid, told trusts to keep occupancy below 92%, and others believe even this is dangerously high, although trusts do often exceed it during winter. Trusts are seeing the largest numbers of non-covid emergency patients since at least winter 2019-20; and are also trying to return as many planned operations as possible. They are doing so with thousands fewer beds than normal, due to measures to deal with ongoing covid patients without further outbreaks of the virus in hospital. Read full story (paywalled) Source: HSJ, 8 June 2021
  4. News Article
    Mental health consultations among new mothers were 30% higher during the COVID-19 pandemic than before it, particularly during the first three months after birth, suggests Canadian research. Study authors noted that postpartum mental illness, including postnatal depression, usually affected as many as one in five mothers and could have long-term effects on children and families if it becomes chronic. They looked at mental health consultations by 137,609 people in Ontario during the postpartum period – from date of birth to 365 days later – from March to November 2020. They found mental health visits to both primary care and psychiatrists were higher than before the pandemic, especially among those with anxiety, depression, and alcohol or substance use disorders. Read full story Source: The Nursing Times, 7 June 2021
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    Why does the packaging of these two eye drop packs look so similar? You have to read the back carefully to see the difference.
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  7. Content Article
    A new best practice guide helping trusts learn more from NHS negligence claims has been issued in the drive for better patient safety. With the cost of harm for clinical negligence claims from incidents in 2019/20 expected to cost the NHS £8.3 billion, the Getting It Right First Time (GIRFT) programme and NHS Resolution have worked together to produce 'Learning from Litigation Claims', offering trust clinicians, managers and legal teams a practical and structured approach to claims learning, and sharing examples of best practice from across England. The aim is to maximise what can be learned from litigation, for the benefit of patients and to curb escalating costs.
  8. Content Article
    Wyndaele et al. evaluated the trends in female stress urinary incontinence (SUI) surgery in a UK tertiary referral centre during five years before the July 2018 tape suspension and to compare it with NHS England data. They found that when all invasive treatment options are transparently presented to female patients with SUI, they prefer other surgical treatments as an alternative to mid-urethral sling.
  9. Event
    The NHS is the biggest UK employer of Black and Minority Ethnic staff. More action needs to be taken to tackle disparities and prejudice to make our NHS more equitable for staff and patients alike. Dr Anu Obaro has recently shared her experiences through a BOB impact story, in which she has reflected on how she presented the subject to her peers at a roundtable event. Join Dr Anu Obaro and guests for a one-hour webinar as they discuss how you can take action to instil anti-racism where you work. In this webinar, you will learn: How racism can be institutionalised. How you can spread and scale the learnings from Dr Obaro’s write-up on BOB. How you can gather data to demonstrate outcomes in your workplace. Register
  10. Content Article
    This report summarises some of the key findings from the full 2020 National Cardiac Audit Programme (NCAP). It provides useful background information and highlights what you can do to help improve cardiac health for you and your friends and family. It includes answers to some frequently asked questions and links to where to go for more information or support.
  11. Content Article
    There is concern among patients, surgeons and health authorities regarding reported adverse patient outcomes following use of mesh in certain urogynaecological surgical procedures. The European Society of Coloproctology (ESCP) has conducted an extensive review of the surgical literature on the outcome of use of mesh in the pelvis of patients who have undergone bowel surgery and will shortly publish its recommendations. ESCP would like to hear from patients who have had both good and not so good experiences with colorectal surgery using mesh such as operations for rectal prolapse (rectopexy), or operations for advanced rectal cancer/inflammatory bowel disease who had mesh inserted to assist in skin closure of the back passage area. The survey is designed to capture the experience of patients who have had an operation that involved using mesh in the pelvis as a part of a colorectal (bowel) surgical operation. The survey is NOT designed to cover outcomes following urogynaecological operations for prolapse or urinary incontinence. The use of mesh as part of abdominal wall hernia repair is also not included.
  12. Content Article
    Tension pneumothorax can occur following chest trauma, respiratory disease and infection, or during resuscitation requiring invasive or non-invasive ventilation. It is a life-threatening condition resulting from a collapsed lung when air trapped in the pleural cavity compromises cardiopulmonary function. Immediate temporary decompression is required to prevent cardiac arrest. This is commonly done by inserting a needle and cannula, usually used for intravenous access, through the chest wall into the pleural cavity (needle thoracostomy). The needle is withdrawn, and the cannula left in place to allow the trapped air to flow out. New blood control (closed system) intravenous cannulas are increasingly used in the NHS; at least 130 trusts bought a total of three million of them in the last year. They look very similar to both traditional and standard safety cannula (with needle guard or shield) but have an extra integral septum which closes when the needle is withdrawn and stops free flow in or out of the cannula. Flow is only possible once an intravenous line or Luer-lock syringe is attached to the hub, which opens the septum. Blood control (closed system) cannulas help prevent blood spillage, exposure and contamination, when used for their intended intravenous purpose, but they cannot be used to decompress a pneumothorax without additional equipment. The main patient safety risks are: staff may select a blood control (closed system) cannula not realising its limitations for this procedure a blood control (closed system) cannula may wrongly be assumed to be functioning in a patient who is deteriorating rapidly a second needle might be introduced risking very significant damage to the lung as it reinflates.
  13. Event
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    To truly improve patient experience and patient care, we need to shift our mindset. In conjunction with considering medical milestones or statistics, healthcare organisations need to consider what the impact of the health condition is on the patient’s life and how they experience their illness. For example, if a child suffers from asthma, as well as determining how frequently they are affected and how many times they need medication, it is crucial to ask how it is impacting their ability to play with their friends. Can they still do sport? Is it stopping them from attending school? While there is a general agreement in the medical field that PRO is important, there are challenges from a time and cost perspective to gathering this information and ensuring that it is then converted into a usable format. This upcoming conference will explore how the challenges and opportunities around how the use of patient-reported outcomes can be improved. Register
  14. Content Article
    Yvonne Ormston shares her experience of dealing with Covid as the CEO of Gateshead Health FT and her own cancer journey during the pandemic. Published in HSJ.
  15. Content Article
    The Patient Safety Authority are inviting PharmD students and faculty to submit their manuscripts by 30 June. A panel of guest editors—pharmacy experts from across the United States—will select their favourites. 
  16. Event
    Join the Patient Safety Movement for a unique opportunity to view the award-winning HBO hit film Bleed Out and talk with the filmmaker, Steve Burrows afterwards. Bleed Out is the harrowing HBO feature documentary film that explores how an American family deals with the effects of medical malpractice. After Judie Burrows goes in for a routine partial hip replacement and comes out in a coma with permanent brain damage, her son, Steve Burrows, sets out to investigate the truth about what really happened. The documentary film takes place in real time over a span of ten years. Tickets
  17. News Article
    A group of patient activists has set up a new website using official NHS data to allow patients to check the waiting times for treatments at their local hospital. The new waiting times tool is thought to be the first automated and regularly updated website that shows hospital performance against key waiting time targets, by medical specialty such as cardiology or orthopaedics. The service, developed by volunteers from the not-for-profit Patient Experience Library, not only shows patients how many people are waiting to be treated overall but also shows data on the median waiting time as well as how well the hospital is performing against targets over time. Patients can also compare different hospitals and look at the performance of the NHS in England overall. Wait times for mental health services are treated separately and not included. Miles Sibley, co-founder of the Patient Experience Library, said the website was an attempt to bring transparency to NHS England’s “impenetrable spreadsheets” which not only affected patients but also other NHS staff who told Sibley they spend hours downloading data and working out their organisations performance. Read full story Source: The Independent, 7 June 2021
  18. News Article
    A trust’s gastroenterology service was ‘in a very poor state with significant risks to patient safety’ and had poor teamworking which “blighted” the service, an external review found. The problems in the service at Salisbury Foundation Trust, Wiltshire, were so severe that the Royal College of Physicians suggested it should consider transferring key services such as management of GI bleeds and the care of hepatology patients to other hospitals. The service was struggling with poor staffing which had led to increased reliance on a partnership with University Hospital Southampton Foundation Trust, outsourcing and the daily use of locum consultants, according to the report. The trust board had identified “inability to provide a full gastroenterology service due to lack of medical staff capacity” as an extreme risk. The report said: “This review was complex and necessary as the gastroenterology service is in a very poor state with significant risks to patient safety and the reputation of the trust. We found a wide range of problems which now need timely action to ensure patients are safe.” Read full story (paywalled) Source: HSJ, 7 June 2021
  19. News Article
    It is more than eight years since Averil Hart died after being found passed out in her university room, but the words left in her diary are etched in her father’s mind. “She said: ‘dear God please help me’ and that was four or five days before she collapsed,” says Nic Hart. “It sums up what many young people desperately need. They need help. Here we are eight-and-a-half years on and what has changed?” Averil, who was diagnosed with anorexia aged 15, was taken to Norfolk and Norwich University hospital at 19 in a “severely malnourished” state but received no nutritional or psychiatric support during her four-day admission, according to an inquest into her death. She was then urgently transferred to Addenbrooke’s hospital in Cambridge. The coroner found a litany of failings. She was treated by doctors who knew “practically nothing” about anorexia. There had been no follow-up from the local eating disorder team and a failure to provide life-saving treatment. The inquest was the last in a series of coroners’ examinations of five women who died from eating disorders while in the care of the NHS in the east of England. “I suppose listening to the NHS arguments on delivery … they would say it is an organisation of a million people and these things [real changes] take time,” her father says. “But you wonder what it takes to turn all these well-meaning policies that seem to come up from time to time into action.” Hart says we need to learn from how the UK has tackled potentially life-threatening conditions such as sepsis and think about how we can “train clinicians to turn this around quickly”. Read full story Source: The Guardian, 6 June 2021
  20. News Article
    An NHS trust has become the first in the country to individually contact every family of patients who caught coronavirus while they were in hospital in a large-scale bid to be transparent over the scale of infections. Bosses at the Queen Elizabeth Hospital Kings Lynn NHS Trust have set up a team to work through hundreds of cases where patients caught coronavirus in hospital. At least 99 patients are known to have died after becoming infected with more cases still to review. In a unique approach to transparency the trust is sending a letter by recorded delivery to every affected patient or family where it is thought the patient picked up the virus within the hospital. The letter offers an apology for what happened and is followed by a phone call with a nurse and a meeting with officials if families have more concerns. Some families have asked to meet the nurses who cared for their loved ones. Read full story Source: The Independent, 6 June 2021
  21. News Article
    Labour has urged the NHS and Matt Hancock to pause their plan to share medical records from GPs to allow time for greater consultation on how the idea would work, saying that maintaining patients’ trust must be paramount. In a letter to the head of NHS Digital and the health secretary, the shadow public health minister, Alex Norris, said Labour backed the principle of improved data collaboration but shared the concerns of some doctors’ groups. The Royal College of General Practitioners warned NHS Digital a week ago that plans to pool medical pseudonymised records on to a database and share them with academic and commercial third parties risked affecting the doctor-patient relationship. NHS Digital needed to explain the plans better to the public, the group said, as well as outlining how people could opt out. The British Medical Association (BMA) has also called for a pause to the General Practice Data for Planning and Research scheme. Another group, the Doctors’ Association, said it was worried it would “erode the doctor/patient relationship, leaving patients reluctant to share their problems due to fears of where their data will be shared”. Read full story Source: The Guardian, 6 June 2021
  22. News Article
    Most people who are reluctant to be vaccinated against Covid are worried about side-effects and whether the vaccines have been adequately tested, a survey in 15 countries has shown. Other reasons cited in the survey of 68,000 people, led by Imperial College London’s Institute of Global Health Innovation in collaboration with YouGov, were the uncertainty that people would not get the vaccine they preferred and worries about efficacy. The survey was carried out in Australia, Canada, Denmark, France, Germany, Israel, Italy, Japan, Norway, Singapore, South Korea, Spain, Sweden, the United Kingdom and the United States. Excluding eligibility, the top reasons for not having the vaccine across all 15 countries surveyed were “concerns about side effects” and/or “concerns that there has not been enough testing of vaccines”. Trust in vaccines was highest in the UK, at 87%, and lowest in Japan, at 47%. The UK respondents also had the highest level of confidence in their health authorities (70%), while South Korea had the lowest (42%). Among those who had not yet been vaccinated, confidence was highest in the Pfizer/BioNTech vaccine in nine out of the 15 countries, and in three others – Canada, Singapore and Sweden – among those under 65. Read full story Source: The Guardian, 4 June 2021
  23. News Article
    A hospital trust has decided to prioritise people with learning disabilities for elective treatment, after analysis showed they were disproportionately affected by lengthy waits for care, along with some people who have a minority ethnic background. The decision forms part of wider analysis at Calderdale and Huddersfield Foundation Trust of how the impact of covid, and work to recover from it, can exacerbate health inequalities and how this can be addressed. The FT said in a board paper it would “initially prioritise [people with a learning disability] for treatment after cancer and urgent patients”. Papers said it wanted to prioritise patients “around health inequalities and need based” rather than chronologically, as part of its covid elective recovery work. It made the decision about people with a learning disability as they have a shorter average life expectancy “and therefore the impact of waiting for treatment can both further reduce this as well as disproportionately impact on their quality of life whilst waiting,” according to trust board papers. Read full story (paywalled) Source: HSJ, 4 June 2021
  24. News Article
    The number of people suffering from symptoms of long covid more than a year after their initial Coronavirus infection has jumped to almost 400,000. New data from the Office for National Statistics based on a survey of patients found the numbers of patients with persistent symptoms after 12 months jumped from 70,000 in March to 376,000 in May. Overall, the ONS said an estimated one million people had self-reported signs of long Covid which last for more than four weeks. The effects of long Covid were reported to be affected the day-to-day activities of 650,000 people, with 192,000 of those saying their ability to undertake day-to-day activities had been limited a lot. Fatigue was the most common symptom reported, with 547,000 people affected. A total of 405,000 people reported a shortness of breath, while 313,000 had muscle aches. More than a quarter of a million patients, 285,000 people, said they had difficulty concentrating. According to the ONS the prevalence of long Covid was higher among those aged between 35 and 69-year-old and women were more likely to be affected than men along with those living in the most deprived areas as well as staff working in health and social care. Read full story Source: The Independent, 3 June 2021
  25. Content Article
    n the UK, while most primary care contacts are uncomplicated, safety incidents do occur and result in patient harm, for example, failure to recognise a patient’s deterioration in health. This study by Cecil et al. determined the patient and healthcare factors associated with potentially missed acute deterioration in health. Differentiating acute deterioration from self-limiting conditions can be difficult for clinicians, particularly in patients with sepsis, urinary tract infections, or long-term conditions. The findings of this study support the call for longer GP consultations and caution against reliance on telephone consultations in primary care; however, more research is needed to understand the underlying mechanisms.
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