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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Nearly 200 families have now reported experiences of poor maternity and neonatal care in East Kent, according to the family whose baby’s death sparked both an independent investigation and a court case against the trust. Baby Harry Richford died seven days after his birth at the Queen Elizabeth, the Queen Mother, Hospital in Thanet in 2017. Next week, the Care Quality Commission is taking East Kent Hospitals University Foundation Trust to court, alleging it failed to meet fundamental standards of care in the treatment of both Harry and his mother Sarah. An independent investigation, led by Bill Kirkup, is also looking into maternity and neonatal services at the trust. In a statement, the Richford family told HSJ they had had numerous contacts from other families who had had bad experiences of maternity and neonatal care at the trust. “We have encouraged such families to come forward to the Kirkup Inquiry and now believe that the number of families is approaching 200,” they said. Read full story (paywalled) Source: HSJ, 16 April 2021
  2. Content Article
    A group of royal colleges has produced guidance for doctors seeing patients who have concerns about symptoms after receiving the Oxford AstraZeneca COVID-19 vaccine. The Royal College of Emergency Medicine, the Society for Acute Medicine, and the Royal College of Physicians say that anyone who presents with symptoms suggestive of COVID-19 vaccine induced thrombosis and thrombocytopenia (VITT)1 should have a full blood count to check their platelet level. Symptoms of concern include persistent or severe headaches, seizures, or focal neurology; shortness of breath, persistent chest, or abdominal pain; and swelling, redness, pallor, or cold lower limbs.
  3. News Article
    A group of royal colleges has produced guidance for doctors seeing patients who have concerns about symptoms after receiving the Oxford AstraZeneca COVID-19 vaccine. The Royal College of Emergency Medicine, the Society for Acute Medicine, and the Royal College of Physicians say that anyone who presents with symptoms suggestive of COVID-19 vaccine induced thrombosis and thrombocytopenia (VITT)1 should have a full blood count to check their platelet level. Symptoms of concern include persistent or severe headaches, seizures, or focal neurology; shortness of breath, persistent chest, or abdominal pain; and swelling, redness, pallor, or cold lower limbs. The advice comes after the HSJ reported that emergency clinicians had raised concerns over a surge in patients attending emergency departments as a result of anxiety over the safety of the AstraZeneca vaccine. Investigations by EU and UK regulators into reports of unusual blood clots after receiving the vaccine concluded that these are a “possible” and “extremely rare” side effect. Katherine Henderson, president of the Royal College of Emergency Medicine, said that following the announcements, patients had been attending emergency departments after receiving the AstraZeneca vaccine. “I saw 21 patients with concerns in an eight hour shift, so we have to have a way of dealing with this. It was important for us to have a strategy for managing those patients that didn’t mean that they were getting over-investigated but they were getting reassurance. We also need to be aware that if somebody has significant symptoms it is always possible, given the rarity of VITT, that it is something else,” she said. Read full story Source: BMJ, 13 April 2021
  4. News Article
    Coronavirus death rates are twice as high in insecure jobs as in other professions, new research suggests. The TUC said workers on a contract that does not guarantee regular hours or income, such as zero-hours contracts or casual work, and those in low-paid self-employment, have been more at risk of infection. It’s thought that key workers such as those in social care and delivery driving, which cannot be done from home and require people to come into contact with others, are more insecure. The COVID-19 mortality rate among men in insecure occupations was 51 per 100,000 people aged 20-64, compared with 24 per 100,000 in more secure work, said the union organisation. The mortality rate among women in insecure jobs was 25 per 100,000 people, compared with 13 per 100,000 in more secure occupations. The TUC, which called the figures stark, said more research was needed to understand the links between precarious work and risk of infection and death. Read full story Source: The Independent, 16 April 2021
  5. News Article
    Senior government officials have raised “urgent” concerns about the mass expansion of rapid coronavirus testing, estimating that as few as 2% to 10% of positive results may be accurate in places with low Covid rates, such as London. Boris Johnson last week urged everyone in England to take two rapid-turnaround tests a week in the biggest expansion of the multibillion-pound testing programme to date. However, leaked emails seen by the Guardian show that senior officials are now considering scaling back the widespread testing of people without symptoms, due to a growing number of false positives. In one email, Ben Dyson, an executive director of strategy at the health department and one of health secretary Matt Hancock’s advisers, stressed the “fairly urgent need for decisions” on “the point at which we stop offering asymptomatic testing”. On 9 April, the day everyone in England was able to order twice-weekly lateral flow device (LFD) tests, Dyson wrote: “As of today, someone who gets a positive LFD result in (say) London has at best a 25% chance of it being a true positive, but if it is a self-reported test potentially as low as 10% (on an optimistic assumption about specificity) or as low as 2% (on a more pessimistic assumption).” He added that the department’s executive committee, which includes Hancock and the NHS test and trace chief, Dido Harding, would soon need to decide whether requiring people to self-isolate before a confirmatory PCR test “ceases to be reasonable” in low infection areas where there is a high likelihood of a positive result being wrong. Read full story Source: The Guardian, 15 April 2021
  6. News Article
    Around 4.7 million people were waiting for routine operations and procedures in England in February - the most since 2007, NHS England figures show. Nearly 388,000 people were waiting more than a year for non-urgent surgery compared with just 1,600 before the pandemic began. During January and February, the pressure on hospitals caused by COVID-19 was particularly acute. NHS England said two million operations took place despite the winter peak. However, surgeons said hospitals were still under huge pressure due to the second wave of Covid, which had led to "a year of uncertainty, pain and isolation" for patients waiting for planned treatment. Speaking on a visit to Dartmouth, Prime Minister Boris Johnson said the government would "make sure that we give the NHS all the funding that it needs... to beat the backlog". He said the situation had been "made worse by Covid", and added: "We do need people to take up their appointments and to get the treatment that they need." Read full story Source: BBC News, 15 April 2021
  7. Content Article
    COVID-19 placed unprecedented pressure on the health and care system. Improvement, which offers systematic approaches that can help adapt to change, would be expected to be a useful asset in the response to the pandemic. Q members, a community of over 4,000 people skilled in improvement, were asked about the role of improvement tools, methods, approaches and mindsets in supporting change during COVID-19. This paper summarises their responses and shares key findings and recommendations for action.
  8. Content Article
    Rochelle P. Walensky, Director of the Centers for Disease Control and Prevention (CDC) and administrator of the Agency for Toxic Substances and Disease Registry (ATSDR), has declared racism a serious public health threat. Adding action to words, she highlighted several new efforts CDC is leading to accelerate its work to address racism as a fundamental driver of racial and ethnic health inequities in the United States. The CDC have unveiled a new website “Racism and Health” that will serve as a hub for the agency’s efforts and a catalyst for greater education and dialogue around these critical issues.
  9. Content Article
    This work from Nurek et al. aims to provide a rapid expert guide for post Covid-19 condition ('long covid') clinical services. In the absence of research into mechanisms, therapies and care pathways, yet faced with an urgent need, guidance based on “emerging experience” is required.
  10. Content Article
    Understand how you can protect yourself as a lone worker as well as how your employer and manager should support you, with this guide from NHS Employers on improving safety for lone workers. It includes a list of key things to consider, which acts as a helpful checklist for those who work alone. The guide is aimed at an increasing number of staff in the health sector who work alone in community settings such as patients’ homes or on outreach work. Lone workers can be vulnerable and at increased risk of physical or verbal abuse and harassment from patients, clients, their relatives or members of the public, simply because they don’t have the immediate support of colleagues or security staff.
  11. Event
    until
    Returning for its 10th run, The King's Fund conference gives you the opportunity to interact with our policy experts, who will guide you through the latest health and social care data and explain how the system in England really works. Register
  12. Content Article
    Following a lengthy consultation, the National Institute for Health and Care Excellence (NICE) has published new guidelines on chronic pain in over 16s. In the new guidelines, NICE made some recommendations for people whose chronic pain has no known cause, including the use of acupuncture. Dr Alice Howarth takes a closer look at the guidelines. 
  13. Content Article
    This rapid review from the BC Patient Safety & Quality Council provides an overview of the role of culture in healthcare settings, including the common limitations and best practices related to the measurement of culture. The review also highlights selected survey instruments, including a description of what is measured by each survey and their relative strengths. No one survey instrument is identified as the gold standard to measure culture in a health care setting. This literature review offers guidance and supports the use of survey tools to generate discussion, provide data for comparison and foster improvement to culture within organisations.
  14. Content Article
    This first webinar of Global Patient Safety Webinar Series 2021 introducing the “WHO Patient Safety Incident Reporting and Learning Systems: Technical report and guidance” which was released on 17  September 2020 on World Patient Safety Day.   The webinar presented an overview of the technical guidance, and the country experiences on implementing and managing the patient safety incident reporting and learning systems.  A recording of the webinar is available below.
  15. Content Article
    The Department of Health and Social Care (DHSC) published its consultation 'Regulating healthcare professionals, protecting the public' with proposals to modernise the legislation of the health professional regulators. Here the Professional Standards Authority gives their views of these proposals.
  16. Content Article
    This guidance aims to support the safe roll-out of COVID-19 vaccination programmes. Vaccination programmes include a number of work systems, such as manufacturing, filling and packaging for distribution, testing and approval, cold chain delivery, booking systems for vaccination appointments, local administration of the vaccine, and patient follow-up. The challenges and requirements for operating such complex programmes at speed may vary both within a country as well as between countries, but the guidelines offer 10 principles to support systems thinking for vaccination programmes that apply across settings. These human factors and ergonomic principles relate to the identification and description of work systems (Identify), the improvement of work systems and processes (Improve), and the continuous learning from experience to achieve sustainable change (Adapt).
  17. News Article
    Relatives of elderly patients have set up a families action group to investigate allegations of “poor level of care” at the Royal London Hospital. The Royal London Hospital Patients and Families Group says it is in talks with lawyers this week after setting up a Facebook page to share their experiences of the east London hospital. Anger erupted after relatives were refused visits to wards during strict lockdown periods and there were claims elderly family members were not receiving attentive care on the wards. Barts Health NHS Trust, which runs the hospital, said the pandemic has been an "extremely busy" time but insisted patient safety is its top priority, while promising to listen to any feedback and concerns. The families' group is calling for changes and suggesting how standards "should be improved" by involving families with patient care. “Many don’t speak English,” the group’s chair Abdul Doyas explained. “They are unable to communicate with medical staff. Allowing a family member to be present during agreed hours will improve care." "Vulnerable people are admitted to hospital in an unfamiliar environment, which is a frightening experience that causes anxiety. But having a family member by their side can improve chances of recovering.” Read full story Source: East London Advertiser, 13 April 2021
  18. News Article
    NHS maternity units have been told they have until next April to increase the numbers of midwives on wards to expected levels after a near £100 million investment. NHS England has told hospitals they must bring staffing levels for midwives up the levels needed to meet their planned demand from mothers and to ensure women get safe care. In a letter to NHS trusts, England’s chief nurse Ruth May said she expected hospitals to use their share of a recent £96 million investment by NHS England to boost staffing levels along with extra spending from local budgets. NHS England has carried out an analysis of demand and supply with Health Education England as part of a four year plan to boost the number of midwives. Hospitals are expected to set the level of midwives needed to deliver more one-to-one care and to try and ensure more than half of women see the same midwife throughout their pregnancy. Read full story Source: The Independent, 13 April 2021
  19. News Article
    A review sparked by the ‘unexpected’ deaths of 13 patients has found several shortcomings in the talking therapy services offered by a mental health trust. The internal review at Tees, Esk and Wear Valleys Foundation Trust followed a series of deaths between October 2019 and September 2020. The trust has said the key findings included a lack of family involvement in discussing risks, increased waiting times for face-to-face therapy, and a lack of contact or reassessment for patients on waiting lists. Eight of the 13 deaths, six of which were suicides, were escalated to serious incident reviews, according to a freedom of information response received by HSJ. However, when asked for the findings of the serious incident reviews, the trust said: “To break down the key issues and attribute any single one of them to an individual patient death would in itself lead to potentially identifying that person.” The trust’s improving access to psychological therapies service assessed 11,839 people between October 2019 and September 2020. It comes amid a series of separate investigations into concerns around the trust’s services. Read full story (paywalled) Source: HSJ, 13 April 2021
  20. News Article
    A care home under investigation over a resident's death has been rated inadequate for the second time. Merseyside Police began investigating Prescot's Griffin House after the death of a 90-year-old man in June 2020. The Care Quality Commission (CQC) rated it inadequate in September, highlighting safety concerns and a report from February, released on 9 April, found it had not improved. The inspection on 24 February found management had failed to adequately address the problems previously identified by the CQC and there were new concerns relating to staff recruitment. Inspectors found medicines were not always administered safely, COVID-19 guidance was not always followed and there was not always enough staff on duty. They also noted some staff had not had proper background checks before starting work, but added that since the inspection, a new system had been introduced to ensure checks were carried out. The report said the home's management "refused to follow government guidelines and participate in lateral flow testing for visitors to the home as they did not believe these tests were accurate". Read full story Source: BBC News, 13 April 2021
  21. Content Article
    New NICE guidelines recommend exercise, rather than medication, for those suffering with chronic pain. Writer Grace Holliday explains why movement alone isn’t enough to help those dealing with symptoms in an article for Stylist. 
  22. Content Article
    VigiBase is the Uppsala Monitoring Centre (UMC)’s starting-point for the journey from data to wisdom about safer use of medicines and wise therapeutic decisions in clinical practice. It is the driving-force at the heart of the work of UMC and the WHO Programme. The purpose is to ensure that early signs of previously unknown medicines-related safety problems are identified as rapidly as possible. VigiBase is the unique WHO global database of individual case safety reports (ICSRs). It is the largest database of its kind in the world, with over 20 million reports of suspected adverse effects of medicines, submitted, since 1968, by member countries of the WHO Programme for International Drug Monitoring. It is continuously updated with incoming reports.
  23. News Article
    Nearly 90% of organisations representing doctors agree that the UK should have a mandatory and public register of doctors’ interests, a survey by The BMJ has found. Last year the Independent Medicines and Medical Devices Safety Review, chaired by Julia Cumberlege, called for the General Medical Council (GMC) to expand its register to include a list of financial and non-pecuniary interests for all doctors. That review investigated harmful side effects caused by the hormone pregnancy test Primodos, the anti-epileptic drug sodium valproate, and surgical mesh. One of its key conclusions was that patients had a right to know if their doctor had financial or other links with pharmaceutical or medical device companies. The BMJ wrote to six faculties, 14 royal medical colleges, and the Academy of Medical Royal Colleges about such a register. It received responses from two faculties, 12 colleges, and the academy, a 71% response rate. Of the organisations that responded, 13 (87%) agreed that there should be a mandatory and public register of doctors’ interests in the UK. Read full story Source: BMJ. 8 April 2021
  24. Content Article
    Visual representation from Steven Shorrock on a quick way to evaluate where you can improve the flows of reporting within your organisation. The red highlights stronger influences.
  25. Content Article
    Few studies have explored the work of sterile processing departments (SPD) from a systems perspective. Effective decontamination is critical for removing organic matter and reducing microbial levels from used surgical instruments prior to disinfection or sterilisation and is delivered through a combination of human work and supporting technologies and processes. In this paper, Alfred et al. we report the results of a work systems analysis that sought to identify the complex multilevel interdependencies that create performance variation in decontamination and identify potential improvement interventions.
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