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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Patients who had longer consultations with their GP were less likely to subsequently self-refer themselves to hospital due to a worsening of their condition, a study has found. The study, which looked at factors associated with potentially missed acute deterioration, said this might be because GPs with more time to assess patients ‘are more likely to recognise deterioration and refer the patient for secondary care’. A longer consultation might also allow GPs more time to provide advice, such as telling the patient to contact the practice again if their condition worsens, the British Journal of General Practice study found. The researchers defined a potentially missed acute deterioration as a patient having a self-referred admission to hospital after being seen by a GP in the three days beforehand. They found that 116,097 patients had contacted a GP three days before an emergency admission, with patients with sepsis or urinary tract infections more likely to self-refer. GP appointment duration was associated with self-referral, with a five-minute increase in appointment time resulting in a 10% decrease on average in the odds of self-referred admissions. Patients having a telephone consultation compared with face-to-face, previous health service use, and the presence of comorbidities were all also associated with self-referred admission, according to the research. Read full story Source: Management in Practice, 2 June 2021
  2. Content Article
    Despite widespread recognition and known harms, serious surgical errors, known as surgical never events, endure. The California Department of Public Health (CDPH) has developed an oversight system to capture never events and a platform for process improvement that has not yet been critically appraised. This study examined surgical never events occurring in hospitals in California and summarize recommendations to prevent future events.
  3. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation looked at the risks involved in the correct identification of patients in outpatient departments. Correct identification is crucial to make sure they receive the right clinical procedure. In the last 10 years the number of patients treated in outpatient clinics has nearly doubled. Many minor surgical procedures can now be carried out in an outpatient clinic, whereas in the past they would have been carried out in an inpatient theatre setting. The high number of patients treated in an outpatient clinic requires efficient management. Clinical consultation and delivery of the required intervention often needs to be completed within a 15-20-minute appointment. In a single outpatient waiting area there may be patients arriving for different clinical interventions. Staff need to make sure that all patients are seen in the right place, at the right time and (if required) receive the right procedure. Outpatients are not provided with any physical means that staff can use to identify them. This is different to inpatients where a wristband is worn following an initial check of the patient’s identity. Checking the identity of a patient in an outpatient department typically relies on staff speaking to patients. There is a risk of patients being missed or misunderstood due to the environment, work demands, language or cultural barriers.
  4. Content Article
    Safety is a key concern in older adult care homes. However, it is a less developed concept in older adult care homes than in healthcare settings. As part of a study of the collection and application of safety data in the care home sector in England, a scoping review of the international literature was conducted by Rand et al. The findings indicate that there are a range of available safety measures used for quality monitoring and improvement in older adult care homes. These cover all five domains of safety in the Safety Measurement and Monitoring Framework. However, there are potential gaps. These include user experience, psychological harm related to the care home environment, abusive or neglectful care practice and the processes for integrated learning. Some of these gaps may relate to challenges and feasibility of measurement in the care home context.
  5. Content Article
    Joint meeting with the British Medical Journal on establishing a register of financial and non-pecuniary interests for doctors.
  6. Content Article
    Improving the design of technology relies in part, on the reporting of performance failures in existing devices. Healthcare has low levels of formal reporting of performance and failure of medical equipment. This paper from Tase et al. examines methods of reporting in the car industry and healthcare and aims to understand differences and identify opportunities for improvement within healthcare.
  7. News Article
    A group set-up following the Winterbourne View scandal is urging more people with learning disabilities to attend their annual health check-up. Healthwatch South Gloucestershire said regular health checks could prevent people from dying unnecessarily. It formed after BBC Panorama exposed abuse of patients at Winterbourne View hospital 10 years ago. Only about 36% of people with learning difficulties are believed to have an annual GP health check-up. The Local Democracy Reporting Service (LDRS). said the lack of regular, medical observations contributed to them having a life expectancy of 20 years lower than in the wider population. Healthwatch South Gloucestershire, a regional, independent health and social care champion, has created a checklist to encourage more people to attend appointments to help them improve their life expectancy. Vicky Marriott from the group said: "It is our unrelenting mission to listen and share people's lived experience so that the information informs how health and social care services improve. "We recently listened to people with learning disabilities and their families and developed with them an accessible info-sheet packed full of easy-to-read explanations about the lifesaving benefits of annual health checks." Read full story Source: BBC News, 1 June 2021
  8. News Article
    The prospect of care home workers being required to get vaccinated against COVID-19 has moved a step closer, with a crucial endorsement from the UK’s human rights watchdog. Ministers are considering changing the law to make vaccination a condition of deployment for people in some professions that come into regular close contact with elderly and vulnerable people at high risk from the coronavirus. In a report to the government seen by the Guardian, the Equality and Human Rights Commission (EHRC) admitted that making vaccines compulsory for care home staff would be a “significant departure from current public health policy”. But they judged that ministers were “right to prioritise protection of the right to life for residents and staff” and said it would be reasonable for care home workers to need a jab “in order to work directly with older and disabled people, subject to some important safeguards”. The EHRC is also likely to make a similar recommendation about healthcare workers, after the vaccines minister, Nadhim Zahawi, suggested over the weekend that NHS staff could face mandatory jabs, too, as some patients were “being infected in hospital”. Zahawi said no decisions had been made yet, and stressed there was a precedent: surgeons were required to be vaccinated against hepatitis B. He added: “It would be incumbent on any responsible government to have the debate, to do the thinking about how we go about protecting the most vulnerable by making sure that those who look after them are vaccinated.” Read full story Source: The Guardian, 2 June 2021
  9. News Article
    Thousands of ambulance crews in England will be given body cameras after a sharp rise in attacks on NHS staff treating patients, the government has announced. Data shows that 3,569 ambulance staff were physically assaulted by members of the public last year – 30% more than in 2016-17. The plans come after successful trials in London and the north-east. The cameras will be given to crews in 10 ambulance trusts across the country. Medics will wear the cameras and be able to press a button to start recording if patients or the public become aggressive or abusive, and the film will be given to the police where needed. Prerana Issar, the chief people officer for the NHS, said: “Every member of our dedicated and hardworking NHS staff has the fundamental right to be safe at work and it is our priority to eliminate violence and abuse, which we will not tolerate. As well as reducing the number of incidents towards our staff, these cameras are a vital step towards ensuring our people feel safe too.” Read full story Source: The Guardian, 2 June 2021
  10. News Article
    Concerns over bullying and discrimination have been raised in a survey of hundreds of doctors at a major hospital trust, HSJ can reveal. University Hospitals of North Midlands Trust’s medical staff committee carried out a survey of its doctors earlier this year, after bullying concerns were raised by members of the British Association of Physicians of Indian Origin at the trust. A summary of the survey findings, published in a newsletter sent to all doctors at the trust last week and seen by HSJ, showed more than two-thirds of the 348 respondents claimed to have experienced bullying, harassment or victimisation at work. Nearly 80% said they had witnessed bullying or harassment, while 50 per cent of respondents said the bullying and harassment was due to race or ethnicity. Fifty-five per cent of those answering the survey also said they had not reported concerns as they had “no confidence in the investigative process within the organisation”. Read full story (paywalled) Source: HSJ, 2 June 2021
  11. Content Article
    Medicine has traditionally been one of the most cognitively demanding occupations. This paper from Bob Baron, President and Chief Consultant of The Aviation Consulting Group, discusses the limitations of human performance in the hospital environment. Human factors models are presented and used as an anchor for a randomly selected case study involving a potentially lethal medication error. The case study’s root cause analysis showed five distinct factors that were causal to the error. The human factors models, in conjunction with an overview of basic human cognition, provide the reader with the tools to understand all five findings of the case study. This paper will provide a foundation for improving medical safety by creating an awareness of the factors that influence errors in medical procedures.
  12. Content Article
    The NHS Race and Health Observatory, supported by three regulators, has called on healthcare leaders to ensure that policies and processes are fair, inclusive and in line with the 2010 Equality Act. Leaders should ensure that health and care staff across the country are protected from racism, or any other form of discrimination, as they go about their vital work. Read the statement in link below.
  13. Content Article
    Sharps injuries (SI) and mucocutaneous exposures (MCE), collectively termed “blood and body fluid exposure” (BBFE), pose a diseases-transmission risk and a psychological stress to health care workers and a responsibility on employers to prevent their occurrence. However, little UK national data is published on their incidence.  The Royal College of Nursing (RCN) present results from a survey of their members.
  14. Content Article
    Mesh-related complications resulting from pelvic organ prolapse (POP) reconstruction operations may be a devastating experience leading to multiple and complex interventions. The aim of the study from Paulo Rodrigues and Shlomo Raz was to describe the experience and time frame of management of mesh-related complications in women treated for POP or stress urinary incontinence in a tertiary centre.
  15. Content Article
    A recording of the recent webinar, moderated by Dr Charlotte Tai, discussing the lessons learnt and advances in practice in diagnosis, treatment, and prevention of ventilator-associated pneumonia. This is available for everyone to watch but you will need to provide an email address to request access.
  16. Content Article
    A new NHS digital platform enabling the health and care workforce to contribute and share a wide variety of learning resources for other learners to use.
  17. News Article
    A woman has died after being "dropped" on the floor during surgery on her hip, which she had broken while in hospital. Jeannette Shields, 70, had been receiving treatment for gall stones in Cumberland Infirmary in Carlisle. North Cumbria Integrated Care NHS Trust said an investigation was under way "in relation to an incident involving a patient in one of our theatres". Mrs Shields' husband, John, said he told the hospital he would not be "pushing this thing under the carpet". His wife left her bed to go to the toilet by herself after getting no response to her buzzer, Mr Shields said. She felt dizzy, fell and broke her hip, he told the BBC. Two days later she had surgery to repair it, after which the hospital called Mr Shields to say the operation had been successful but that "unfortunately they dropped her off the operating [table] after the surgery", he said. "Then they had to use the sliding board to pick her up and rush her in and do scans on her," he said. "She had a great big bump on the back of her head and she just deteriorated and then she just passed away, just died. It is not clear what happened or how Mrs Shields ended up falling from the operating table. Read full story Source: BBC News, 28 May 2021
  18. Content Article
    West Midlands Ambulance Service has highlighted the death of a woman which it says was due to “being delayed on the back of an ambulance”, just two days after it warned that lives were ‘at risk’ from long handovers. Below is the full account from the organisation's board paper.
  19. News Article
    NHS staff at GP surgeries are facing unprecedented abuse and aggression from patients, while stressed doctors are increasingly suffering from mental illness, because of an appointments system “in meltdown”, family doctors’ leaders have revealed. The scale of the deep crisis in GP surgeries was revealed in an emergency summit of more than 60 NHS doctors, dentists and administrative staff in Salford, which the Guardian attended, triggered by a recent rise in verbal abuse. "Patients are short-tempered and not happy waiting for anything … They want letters. The latest one was a request to speak to a GP because he needs a letter to confirm anxieties that cause him a problem in long queues – because he wants to take his son to [Southport amusement park] Pleasureland and does not want to queue," says Jan Crowshaw, a GP manager It comes after a recent poll by the body representing GP surgery staff across the UK found that 75% of them face abuse every day, including assaults, threats, racism and sexism. Read full story Source: The Guardian, 28 May 2021
  20. News Article
    More needs to be done to bring maternity units at a city's two main hospitals up to scratch, inspectors have said. In 2020 the Care Quality Commission (CQC) found serious concerns at Nottingham University Hospitals NHS Trust and labelled the units "inadequate". A new report concluded the trust still has "some areas to address". In October a coroner said the death of Wynter Andrews minutes after she was born was "a clear and obvious case of neglect". Nottinghamshire assistant coroner Laurinda Bower also revealed a 2018 whistle-blowing letter from midwives to trust bosses outlining concerns over staffing levels as "the cause of a potential disaster". In the same month "in response to concerns raised... and coronial inquests", the CQC carried out an unannounced inspection at the hospital and found some staff had not completed training and "did not always understand how to keep women and babies safe", and issued a warning notice over its concerns. Its latest report, based on an inspection in April, found improvements in the way women at risk of deterioration were identified and found documentation and monitoring had improved. However the CQC found a disconnect between online and paper record-keeping and said there were multiple systems in place that led to duplication and errors at times. Read full story Source: BBC News, 28 May 2021
  21. News Article
    Surgeons are calling for specialist hubs in England to help tackle what they call a "colossal backlog" of non-urgent operations because of COVID-19. The Royal College of Surgeons (RCS) wants a network of hospital sites focused on routine surgery, such as hip and knee replacements. The government says it is working "to accelerate the recovery of services". In March, around five million patients were waiting for surgery - the highest number since modern records began. Prof Neil Mortensen, president of the RCS, said the pandemic has had a devastating impact on surgical services - and that it must not be allowed to happen again. "Surgery must be available on the NHS all year round, not stop and start," he said, adding that a "New Deal for Surgery" was required to help weather future pandemics. If a dangerous new variant of COVID-19 takes hold, or another bad flu arrives in the autumn, we cannot allow surgery to grind to a halt again or waiting lists will become insurmountable." Read full story Source: BBC News, 28 May 2021
  22. News Article
    It was 4am on a Sunday in San Antonio, US, when Dana Jones heard an ominous sound, barely audible over the whirring of box fans, like someone struggling to breathe. She ran down the hall and found her daughter Kyra, age 12, lying on her back, gasping for air. Terrified, she called 911. A police officer, the first to arrive, dashed into Kyra’s bedroom, threw the slender girl over his shoulder and laid her on a leather sofa in the living room. He asked her mother, an oral surgery technician, to give her CPR. Kyra’s lips were ice-cold. An ambulance whisked the girl to Methodist Children’s Hospital, where staff members swarmed her and put her into a medically induced coma. Kyra, who has sickle cell, had suffered a devastating stroke — her second — a common complication of this inherited disease, which afflicts 100,000 Americans, most of them Black. She most likely would never have had the strokes if she had been given an annual screening test and treatment proven more than two decades earlier to prevent 9 out of 10 strokes in children with the disease and recommended by the National Institutes of Health. But like countless other children with sickle cell, she was never screened. Read full story Source: New York Times, 23 May 2021
  23. News Article
    An ambulance trust has highlighted the death of a woman which it says was due to “being delayed on the back of an ambulance”, just two days after it warned that lives were ‘at risk’ from long handovers. West Midlands Ambulance Service University Foundation Trust’s board papers this month reveal the woman in her 90s — who has not been named — was taken to hospital because a severe nose bleed would not stop. Its clinical quality board paper says the “patient story” showed ”how a patient being delayed on the back of an ambulance resulted in significant deterioration and ultimately the death of a patient”. Read full story (paywalled) Source: HSJ, 28 May 2021
  24. Content Article
    The Care Quality Commission's (CQC) new strategy strengthens its commitment to deliver their purpose: to ensure health and care services provide people with safe, effective, compassionate, high-quality care and to encourage those services to improve.
  25. News Article
    The number of people being admitted to hospital with COVID-19 is rising in some regions but "few, if any" are from care homes, according to an NHS leader. Younger people are making up most of coronavirus hospital admissions, with 70% of admissions in one hospital consisting of under-45s, NHS Providers chief executive Chris Hopson said. Although the number of hospital admissions is "ticking up" in areas most affected by the Indian Covid variant, the rise is small compared with the levels seen earlier in the year. Speaking to Times Radio, Mr Hopson said most hospitalisations were among younger people and those who have been offered the vaccine but have yet to take up the offer. A number are among those who have only had their first dose of a COVID-19 vaccine, while “a very small number” are fully vaccinated with both doses. Read full story Source: The Independent, 26 May 2021
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