Jump to content
 View Profile  See their activity

  • Posts

    11,589

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

Everything posted by Patient Safety Learning

  1. News Article
    Younger adults are particularly affected by the rare blood clotting disorder linked to the Oxford-AstraZeneca vaccine, the UK's medicines regulator has said. The Medicines and Healthcare products Regulatory Agency (MHRA) said there were 209 cases in the UK of the rare combination of blood clots with low platelet counts following being vaccinated the Oxford-AstraZeneca jab, with 41 deaths, up to 21 April. This is up from 168 cases and 32 deaths the previous week. The new data also shows 24 cases of clots in people aged 18 to 29, 28 in those in their thirties, 30 in people in their forties, 59 in people in their fifties and 57 in those aged 60 and above, with the age not known in the remaining cases. The numbers appear to rise with age but that is because more older people have been vaccinated. Fewer than one in five clots was fatal. The latest NHS England data show that 5.5 million people under 45 had received a first dose by 25 April, while 22.6 million of those 45 and over had done so. MHRA chief executive June Raine said no medicine or vaccine was without risk, but that blood clots were extremely rare. She added: “The benefits of the vaccine continue to outweigh the risks for most people. It is still vitally important that people come forward for their vaccination when invited to do so." Read full story Source: The Independent, 3 May 2021
  2. Content Article
    Bev Curtis, Medical Device Safety Officer (MDSO) at Harrogate & District NHS Foundation Trust, describes the role of the MDSO in this presentation.
  3. News Article
    Tees, Esk and Wear Valleys NHS FT has launched a deaf digital inclusion project, to find the best practice for communicating with deaf and deafblind patients. The project will look at the barriers faced by the patients around digital communications, and how to help the staff become more deaf aware. The deaf and deafblind patients supported by the trust, their carers, staff, and members of deaf wellbeing groups and networks, are taking part in the project to help provide the best digital communications support to meet deaf patients’ needs. The project is led by the trust’s deaf services team which provides a range of support to deaf and deafblind people aged 18 and over, who mainly use British Sign Language (BSL) to communicate, who also have mental health problems. Emmanuel Chan, Clinical Nurse Specialist for the deaf services team, :explained: “People who are oral and require lip reading can find video appointments a challenge if others on the call are not fully deaf aware and talk over one another. Alongside our project, our team aims to help our staff become more deaf aware to avoid this happening.” Read full story Source: NHE, 26 April 2021
  4. Content Article
    REACT-1 is the largest population surveillance study being undertaken in England that examines the prevalence of the virus causing COVID-19 in the general population. It uses test results and feedback from over 150,000 participants each month. The findings will provide the government with a better understanding of the virus’s transmission and the risks associated with different population subgroups throughout England. This will inform government policies to protect health and save lives.
  5. News Article
    A consultant at St Luke’s Hospital in Kilkenny who carried out unauthorised research on five female patients during routine gynaecological procedures has failed in a High Court challenge to prevent his dismissal by the HSE. Consultant gynaecologist Ray O’Sullivan claimed a decision by the HSE’s chief executive, Paul Reid, on December 23rd, 2019 to recommend his dismissal was “fatally flawed” for reasons including a failure to allow him the opportunity to comment on an expert’s report into his professional performance. The hospital began an investigation after nursing staff expressed concern about the risk of infection from a procedure carried out on five patients on September 4th and 5th, 2018 under the direction of Prof O’Sullivan. A catheter and small pressure pad was placed, without their consent and without seeking approval from the hospital’s ethics committee, inside the vagina of five patients who were having a hysteroscopy. This was done as part of a feasibility study designed to see if certain procedures could be carried out without the use of a speculum (a device commonly used in vaginal exams) . The court heard the five patients, who were tested for infection including HIV, were greatly shocked and upset when St Luke’s informed them about what happened at open disclosure meetings. Read full story Source: The Irish Times, 27 April 2021
  6. Content Article
    A recording of a recent BMJ webinar for clinicians. researchers and policy makers on post-covid conditions.
  7. Event
    until
    In this webinar from BAME Birthing With Colour, the panel shares their experiences of what communication on the maternity frontline means in practice. They'll discuss what it takes to deliver critical information clearly and sensitively across a range of scenarios - what works and hasn't worked - as well as the tools available to support the clearest of communication and highest quality of care for women, babies and their families. Join the webinar to discuss: The realities of communication on the maternity frontline. Lessons learned and what to watch out for. Cultural sensitivity. Language barriers. Different levels of understanding. How can staff know they have communicated clearly? The tools available and being developed. Register
  8. Content Article
    The Healthcare Safety Investigation Branch (HSIB) have identified a safety risk involving outpatient follow-up appointments which are intended but not booked after an inpatient stay. If a patient does not receive their intended follow-up appointment, it could lead to patient harm owing to delayed or absent clinical care and treatment. The investigation was launched after HSIB identified an event where a patient was discharged from hospital on two separate occasions with a plan to follow-up in outpatient clinics. Neither of the outpatient appointments were made.
  9. Content Article
    Core Cognition have produced some helpful infographics for staff working under pressure, including fatigue and cognitive performance, cognitive biases and diagnostic error and8 tools to improve communication under pressure,
  10. Content Article
    This blog is the introduction to a joint series of blogs and video conversations exploring how we can improve patient safety through the application of principles of high reliability in healthcare, made collaboratively by Patient Safety Learning and RLDatix.
  11. News Article
    A man who died from lung cancer might have been saved if a hospital trust had not "failed to act" on two abnormal chest X-rays, an investigation found. Growths identified in the patient's examinations were not followed up for three years and were then untreatable, the health ombudsman said. North Cumbria University Hospitals NHS Trust also failed to correctly handle a complaint from the man's daughter. The trust, which runs hospitals in Carlisle and Whitehaven, apologised. The investigation was carried out by the Parliamentary and Health Service Ombudsman (PHSO), which deals with unresolved NHS England complaints. The patient, referred to only as Mr C, was admitted twice to hospital with stroke-like symptoms in 2014 and 2015. On both occasions X-rays were carried out which found abnormal growths in his lungs, but no action was taken. In July 2017, Mr C was found to have advanced lung cancer and he died weeks later. Read full story Source: BBC News, 29 April 2021
  12. News Article
    The Equality and Human Rights Commission has required an ambulance trust to sign a legally-binding agreement stating how it will protect its staff from sexual harassment. This is thought to be the first time the EHRC has taken such action against an English NHS organisation and follows repeated concerns about the culture at East of England Ambulance Service Trust. As a result, EHRC will now monitor the trust’s action plan for protecting staff from sexual harassment. The Care Quality Commission asked the EHRC to consider taking enforcement action against the trust last summer, after a CQC investigation found evidence of “bullying and predatory behaviour” and warned the trust’s leaders were not adequately promoting patients’ and staff’s wellbeing. The CQC also found at least 10 incidents in 2019-20 involving allegations of sexual assault, harassment or inappropriate behaviours, and 13 instances of staff, including those working for subcontractors, being referred to the police for sexual misconduct and predatory behaviour. The trust was subsequently placed in special measures for quality. Read full story (paywalled) Source: HSJ, 28 April 2021
  13. News Article
    Three private mental health hospitals have been placed in special measures after the Care Quality Commission found concerns over infection control. John Munroe Hospital and Edith Shaw Hospital, both in Staffordshire and run by the John Munroe Group, were inspected after the CQC received several whistleblowing complaints over poor covid-19 infection control and covid deaths. A third hospital, Priory Hospital Arnold, based in Nottinghamshire, was criticised over hygiene and infection control failures after the regulator found dried blood, faeces, food and sputum on seclusion room walls. In reports published this week, the CQC revealed it had placed all three hospitals in special measures and imposed urgent enforcement action against the providers. Read full story (paywalled) Source: HSJ, 29 April 2021
  14. Content Article
    StopSIM is a coalition of mental health service users and allies who have grave concerns about the rapid, widespread rollout of the High Intensity Network’s ‘Serenity Integrated Mentoring’ (SIM) intervention across NHS England. The intervention is designed for people who have not committed a crime, but are in contact with mental health services, are frequently at high risk of suicide and self harm and are deemed “high intensity users” of emergency services. Key intervention components include a co-ordinated withholding of potentially life saving treatment by multiple agencies (A&E, mental health, ambulance and police services) and, using SIM’s own words, the “coercive” approach of a police officer as an interventionist.  
  15. News Article
    A nurse says the effects of "long Covid" mean she is "not the same person any more". Lynne Wakefield from Holyhead is still suffering with fatigue and "brain fog" after contracting Covid in June 2020. She said her employer had been "very good" supporting her, but other NHS staff told BBC Wales they felt pressurised to go back to work. The NHS Confederation said there was a package of support for staff affected by "longer term effects of Covid". A recent survey suggested about 56,000 people in Wales have symptoms of long Covid, which include fatigue, headaches and coughing. Other NHS workers with long Covid symptoms, who did not want to be named, told BBC Wales Live how they feel about the ways they are being treated by their employers: "I knew that returning to work would put my recovery at risk, but it was work or starve. On my return, I was informed that any further days absent in the next 12 months would result in a formal warning." "I'm so worried about losing my job as I've been off work for so long and I'm still nowhere near well enough to return." "If they say I have to come back or be dismissed, I'll have to do it, I'll have to try [and go back] and survive. I am so emotional at the moment, I can't stop crying - I feel I am going crazy." Read full story Source: BBC News, 28 April 2021
  16. News Article
    A cutting-edge child and adolescent mental health centre hopes to help prevent young people from experiencing mental health problems. As we look hopefully towards a June bonfire of pandemic regulations and restrictions, many recognise that soaring rates of mental health problems and distress amongst our children and young people must be near the top of a 21st century list of challenges in “building back better”. School closures, uncertainty and being cut off from friends and social and sporting events have seen more children and young people referred to CAMHS — a service that was facing growing demand even before the pandemic. The long-term impact is obviously still unknown. However, a cutting-edge child and adolescent mental health centre opening in south London two years from now will play a big role in responding to the likely increased demand for ongoing support — and in developing innovative treatment responses. Read full story (paywalled) Source: HSJ, 27 April 2021
  17. News Article
    The vaccination rate for staff at older care homes is below the recommended level set by scientists in more than half of England’s local authorities, analysis of NHS England data has revealed. Data as of 18 April shows that 76 out of 149 LAs had not reached the 80% vaccination threshold for care home staff to provide a minimum level of protection against COVID-19, according to the PA news agency. In 17 areas, less than 70% of staff had received a first jab. Lambeth, where 23 cases of a South African COVID variant have been recently reported in a care home, had the lowest uptake at 52.4%. The government last week announced the launch of a five-week consultation on mandatory staff vaccination as a result of the failure in some areas to reach the designated threshold. Read full story Source: Care Home Professional. 23 April 2021
  18. News Article
    The suicide of a woman with severe mental illness has prompted a review into the care of hundreds of other patients, according to her family. Frances Wellburn, 56, was under the care of Tees, Esk and Wear Valley Foundation Trust’s community mental health team in York, which before the coronavirus pandemic had categorised her as “medium risk”. This meant she should have had regular contact from the service, but an internal serious incident report into her death, seen by HSJ, found no contact was made with her for three months. In June 2020 she required admission to an inpatient unit for three weeks, but she deteriorated again after being discharged and took her own life in August. Her family have said Ms Wellburn was making a “good recovery” from episodes of psychosis prior to the pandemic, but the lack of support in the spring of last year had contributed to a major deterioration in her condition. According to sister, Rebecca Wellburn, the trust’s director of nursing Elizabeth Moody confirmed in a meeting with the family that a wider review had now been launched into the care of hundreds of patients under its York-based community services. Read full story Source: HSJ, 28 April 2021
  19. News Article
    NHS whistleblowers have required counselling and medication and a quarter would not raise concerns again due to the stress and lack of support, a report found. A review of existing policy at NHS Greater Glasgow and Clyde found “concerning” evidence of a significant impact on the mental health of both whistleblowers and managers with little support provided. It found there was “no clear documented process” to highlight serious, urgent issues to the appropriate manager. Healthworkers’ union Unison said staff were often labelled ‘trouble-makers’ with senior managers "defensive from the outset". Sixty percent of staff reported that their mental health was negatively impacted by whistleblowing with some requiring counselling or medication to cope with the stress of disclosures. The report said it was of concern that a quarter of staff stated that they would not raise concerns such as unsafe clinical practices again given their experiences, a figure which it said was likely to be higher as this information was only recorded if it was volunteered by staff. Unison’s Regional Organiser Matt McLaughlin said, “Unison welcomes this paper and the Boards commitment to follow the updates national guidance. “However it will take more than a new policy for whistleblowers to feel valued within NHS GGC. The organisation is too defensive and staff who whistleblow often do so out of shear frustration that legitimate concerns are ignored – or worse, where the whistleblower is seen as a trouble maker. " "NHS Greater Glasgow and Clyde needs to embrace and welcome staff speaking out; rather than being defensive from the outset." Read full story Source: The Herald, 28 April 2021
  20. Content Article
    Serenity Integrated Mentoring (SIM) is a new program being introduced in London aimed at improving coping mechanisms and reducing emergency service use in High Intensity Service Users (HISUs). In this feasibility study, Anokhina et al. an evaluation of SIM effectiveness was assessed using demographic data. Three SIM boroughs (Greenwich, Camden and Islington) were compared with a non-SIM borough (Enfield) on emergency service use and costs in the 12 months prior to SIM and 9 months after. Qualitative interviews were conducted with SIM practitioners and service users. They found hat service users did attend A&E less, and were being arrested less, but this was true for both SIM and non-SIM participants. The economic analysis also showed that, at this stage, we cannot see any cost savings to service use yet. These results are something we expected because of the small scale of the study. However, we found that the quality of the data that is recorded by emergency services would allow us to carry out a full-scale study which would give us clearer answers
  21. Content Article
    The United States has been the site of significant social and economic fallout during the course of the coronavirus (COVID-19) pandemic. The last year has been marked by high rates of unemployment, stress, economic insecurity, and uncertainty. And for people with mental health and substance use disorders, the consequences of the pandemic have been felt deeply. As vaccines for people in the United States become more widely available, understanding the impact of the pandemic on substance abuse and treatment remains important for determining the next steps and helping those in need of care. In this blog, AddictionResource.net describe some of the ways that the coronavirus pandemic has affected the lives of people with substance use disorders over the past year.
  22. Content Article
    This Healthcare Safety Investigation Branch (HSIB) report highlights a gap between the NHS and other safety-critical industries in identifying and managing barriers to reduce the risk of serious incidents occurring.
  23. Event
    until
    The Healthcare Safety Investigation Branch (HSIB) would like to invite you to their webinar marking the launch of the new report ‘Management of chronic asthma in children aged 16 years and under’. Asthma is the most common lung disease in the UK, and diagnosis and management of the condition, particularly in children and young people can be complex. The case study in our investigation features a 5 year old who had a near fatal asthma attack. In this webinar you will hear from families, our HSIB investigators and from experts in respiratory illness including Dr Jen Townshend and Professor Andrew Bush. The webinar will provide an opportunity for you to explore in greater depth our findings, what we are recommending to improve the outcomes of children and young people with asthma, and give you an opportunity to ask questions. This webinar will help you understand how HSIB’s experience can be applied to your own healthcare setting, as well as finding out what work will be undertaken nationally to implement our recommendations. Register
  24. Content Article
    The Doctor Will Zoom You Now was a rapid, qualitative research study designed to understand the patient experience of remote and virtual consultations. The project was led in partnership with Traverse, National Voices and Healthwatch England and supported by PPL. The study engaged 49 people over 10 days (June 22nd – July 1st 2020) using an online platform, with 20 additional one to one telephone interviews. Participants were also invited to attend an online workshop on the final day of the study. Using insight from the key findings from the research, this website provides useful tools and tips for getting the most out of your appointment.
  25. Content Article
    Miscarriage is common, affecting one in ten women in their lifetime, with an estimated 23 million miscarriages globally. Despite this, the impact and consequences of miscarriage are underestimated, resulting in an attitude of acceptance of miscarriage and system of care which is currently fragmented and can be of poor quality. A new series of three papers published in The Lancet reviews this evidence on miscarriage and challenges many misconceptions. The authors, Siobhan Quenby, Arri Coomarasamy, and colleagues, call for a complete rethink of the narrative around miscarriage and a comprehensive overhaul of medical care and advice offered to women who have miscarriages.
×
×
  • Create New...