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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
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    In this webinar, Dr Sam Shah, Chief Clinical Digital Advisor, ORCHA, will be joined by Ellie Bryant, Senior Innovation Consultant, Macmillan Cancer Support; Amanda Begley, co-founder and National Director for the NHS Innovation Accelerator (NIA) and Director of Innovation and Implementation, UCL Partners and Dr Tom Micklewrigh. The webinar will discuss: The findings from ORCHA's latest report: Digital Health for Cancer Services. The Macmillan Cancer Support Curated Content project working with ORCHA. The opportunity for innovation in the cancer pathway. Examples of high-scoring apps that can help cancer patients. Suggestions for ways that services can embed five of these apps. Register
  2. Content Article
    A reported 40,000 fewer people started cancer treatment in 2020 due to COVID-19. As a result, for years to come, cancer services will need to diagnose and treat substantially more people, with many requiring urgent care.
  3. Content Article
    Jamie Lee Poole was diagnosed required the lifesaving surgery of a kidney transplant in 2011. After the transplant she was placed on a dose of immunosuppressant to prevent rejection of the transplanted kidney. One of the known side effects of the use of the medication is that it can cause low levels of magnesium within the body. Jamie was admitted to the Royal Stoke University Hospital on 27 June 2017 with low levels of magnesium and low calcium and was treated for correction of electrolyte disturbance. On the 28 June 2017 she was found on the floor having collapsed. It was discovered that she had significant swelling on her brain. This was caused by a lack of oxygen to the brain, which was either caused by a heart problem or a seizure, which on balance would have been caused by the low levels of magnesium. She was transferred to the intensive care unit at the Royal Stoke University, Stoke-on-Trent where she died.
  4. Content Article
    In 2015 the Supreme Court judgement in the case of Montgomery v Lanarkshire Health Board created a significant change to the law in regard to gaining informed, or valid, consent. The case concerned Nadine Montgomery, a pregnant lady of small stature with diabetes who delivered her son vaginally in 2001. Her son experienced a hypoxic insult as a result of shoulder dystocia and consequently suffered cerebral palsy with severe disabilities. She successfully argued that had she been informed of the risk of shoulder dystocia she would have opted to have an elective caesarean section. This is part of NHS Education for Scotland's Advanced Practice Toolkit repository for credible and supportive resources.
  5. Content Article
    Patient safety alerts are issued to providers of NHS care to support them to take specific actions to keep patients safe. Although some content of past alerts is outdated, some of the actions from previously issued alerts continue to be relevant and remain valid beyond the timescales of the original alert. Over 140 alerts issued up to November 2019 (including ‘notices’ or ‘rapid response reports’) were recently clinically reviewed to identify which actions within those alerts remain valid and should be considered as ‘enduring standards’. The review covered alerts issued by the NHS England and NHS Improvement National Patient Safety Team and its predecessor organisation, the National Patient Safety Agency (NPSA). The review also summarised other content from the alerts identified as general principles that can be applied more widely to inform wider ongoing safety improvement. The key elements from the review are highlighted. The pages do not set out any new actions for organisations to implement, but act as an aid to support providers to confirm that ‘enduring standards’ from previously completed alerts have been embedded locally, and that the general principles are considered within ongoing patient safety improvement.
  6. Content Article
    The recent UK government report on race disparities is a missed opportunity and will lead to a worsening of systemic inequalities, say Razai, Majeed and Esmail in this BMJ Opinion article.
  7. Content Article
    In this report, the government sets out reforms to the public health system in England and invite you to share your insights and experience to help them with the next stages of our work. Your feedback will help to shape the future of the public health system. This update focuses on structural reforms, which are a vital enabler of delivering better and more equal outcomes on public health, but they are just one aspect of public health reform. Its focus is the public health system for England, but chapter two highlights the interaction with important UK-wide elements of our health protection response. A further update will be published later in 2021 with final details on design, structure and implementation, and it will also set out government's plans for the policies, delivery and outcomes they want this reformed system to drive and deliver.
  8. Event
    This national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) which has now been published for the early adopter sites as introductory guidance. NHS Improvement will then work with a small number of early adopters to test implementation. For all other organisations the PSIRF is being published for information only and using learning from the pilot sites, resources and guidance will be developed to support organisations to adopt and implement PSIRF, with an expectation that providers and local systems will begin transitioning to the PSIRF from Spring 2022. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement. Register
  9. Content Article
    How have health inequalities impacted the course of the pandemic? How do we optimise infection control across newly-opening schools? And finally: how can we overcome the barriers to wider understanding and recognition of Long Covid (Post-Acute Covid-19 Syndrome)? Dr Nisreen Alwan (University of Southampton) joins LivedHealth hosts Lere and Monique for this episode of Covid in the News to share her personal and professional experience on some huge, important questions for the community.
  10. News Article
    Unpaid carers looking after terminally ill friends and relatives during the pandemic struggled to access pain relief, with some patients dying in unnecessary pain, a survey has found. The survey of 995 unpaid carers by Marie Curie also found people had difficulties getting personal care and respite nursing for loved ones. Figures show the number of people dying at home rose by 42% in the past year. Nearly two-thirds of carers surveyed by the charity said their loved one did not get all the pain relief they needed when they were dying. Susan Lowe, from Solihull, cared for her mother Sheila before she died with bowel cancer in April last year, aged 74. She said caring for her mum during lockdown was hard as "the system was just under so much pressure that we had to manage largely on our own". The public health worker says she struggled to get the right pain relief medication for her mother in her final weeks and spent hours travelling to different chemists. Susan, 50, told the BBC: "My biggest regret is that my mum died in pain - more pain than she needed to be. She really wanted to be comfortable at the end. She knew she was dying." "What she really wanted - and this is what she was assured would happen - was to be comfortable. She was told she would get the drugs that she needed for it to be as bearable as possible... I remember breaking down in tears a couple of times in the pharmacy when I was told the medication mum needed wasn't in stock." Read full story Source: BBC News, 8 April 2021
  11. News Article
    GPs should only give the Oxford/AstraZeneca Covid vaccine to patients with medical conditions which put them at higher risk of developing blood clots if the benefits outweigh the risks, the UK medicines regulator has said. The Medicines and Healthcare products Regulatory Agency (MHRA) has issued the advice to healthcare professionals regarding while it continues to review a link between the vaccine and rare blood clots. It has also added to previous advice regarding symptoms for patients to look out for following their Covid vaccination with the AZ vaccine. The new advice from the MHRA said: Administration of Covid-19 Vaccine AstraZeneca in people of any age who are at higher risk of blood clots because of their medical condition should be considered only if benefits from the protection from COVID-19 infection outweighs potential risks. Anyone who experienced cerebral or other major blood clots occurring with low levels of platelets after their first vaccine dose of Covid-19 Vaccine AstraZeneca should not have their second dose. Anyone who did not have these side effects should come forward for their second dose when invited. Pregnancy predisposes to thrombosis, therefore women should discuss with their healthcare professional whether the benefits of having the vaccine outweigh the risks for them. Meanwhile, ‘anyone who has symptoms four days or more after vaccination is advised to seek prompt medical advice’. These include: a new onset of severe or persistent headache, blurred vision, confusion or seizures develop shortness of breath, chest pain, leg swelling or persistent abdominal pain, unusual skin bruising or pinpoint round spots beyond the injection site. Read full story Source: Pulse, 7 April 2021
  12. News Article
    An acute trust is reviewing thousands of gastroenterology cases for possible patient harm, after details emerged of an ‘extremely concerning’ list of patients who have not had follow-up appointments for up to six years since being treated. HSJ understands major concerns have been raised internally at Liverpool University Hospital Foundation Trust, over 9,500 patients who received treatment at Aintree University Hospital as far back as 2015, but have not had a follow-up appointment. Whistleblowers have also contacted the Care Quality Commission, which has confirmed it is looking into the issues. Well-placed sources said around 7,000 of the cases have “target dates” for an outpatient follow-up that are in the past. Around 20 of these cases were supposed to be seen in 2015 or 2016, with around 400 dating back to 2017, and around 900 to 2018, the sources said. The remaining 2,500 cases either have no target date or have not yet had a follow-up appointment booked. Read full story (paywalled) Source: HSJ, 8 April 2021
  13. News Article
    Health coach Jasmine Hayer had to give up her life in London and move back in with her parents after catching Covid. Now she is focused on a twin goal - battling back to health while helping others get the right treatment for Long Covid. Dr William Man, the head of the Royal Brompton Hospital's chest clinic, started treating her in December, as part of a clinic seeing 100 severe long Covid cases in the UK. Jasmine describes it as a "complete game changer". However, she worries that other so-called "long haulers" are not getting the help they need because they face "such a battle" to be taken seriously. She decided to start a blog to document her symptoms and wants to share her story as widely as possible in the hope of helping others. "I've had messages from around the world and I was so happy to hear that one girl has shown her doctor my blog and he is giving her more tests as a result," she says. "I know how lonely and scary it is when you are fighting to be believed. You are literally on your own." Read full story Source: BBC News, 7 April 2021
  14. News Article
    A rugby player has developed a wearable device to monitor head trauma after a teammate was forced to stop playing the sport due to injury. Euan Bowen, 28, played the game at university and in his final year in 2018, when a teammate suffered three concussion injuries in one season. It spurred Mr Bowen to develop an idea for a device to track brain health into the HIT Impact technology, which detects g-force and records impact on an app. After spending time at Heriot-Watt University’s Edinburgh Business School (EBS) Incubator, his product is expected to move into production within the next two months. The sensor he developed can clip on to headguards, any helmet or halo headband and is accompanied by an app which has a 150-metre range capable of recording from multiple devices - with a "Team Play" recording function for sports like football and rugby. It displays a graph showing the force threshold, set by a user, and severity, with a traffic light system and notifications enabling those monitoring to check on a user's injury. Kallum Russell, EBS Incubator manager, said it is "much-needed technology", adding: "The current parliamentary inquiry into concussion recently heard evidence about the long-term implications of repetitive head trauma on sports people, with MPs asking how sports could be made safer. Read full story Source: The Independent, 8 April 2021
  15. Content Article
    With 1 in 10 people with coronavirus still have debilitating symptoms six months on, people professionals will need to keep sickness policies and return to work front of mind writes Elizabeth Howlett in this article for People Management.
  16. Content Article
    There is a well-described mismatch between the research that is done on a particular condition and the research that patients themselves would like to see done. Formal research priority-setting partnerships aim to reduce this mismatch by involving patients in the selection of topics for research. The National Institute for Health Research (NIHR) has strongly supported patient and public involvement (PPI) in research, produced national benchmarks for PPI, funded INVOLVE (www.invo.org.uk) which promotes patient involvement in all aspects of biomedical research, and written up some exemplar case studies. Trish Greenhalgh looks back at the history of patient involvement in research and suggests a vision for an institute for patient-led research.
  17. Content Article
     This Joint Committee International handbook offers checklists for healthcare staff to keep themselves safe from chemical and physical hazards, infectious agents, workplace violence, ergonomic problems, work-related stress, and more. The book also includes managers’ checklists to ensure that the right administrative controls and processes are in place to safeguard health care staff. All checklists are based on authoritative, evidence-based sources that have proven valuable. All the checklists are straightforward and easy to use and understand and cover the key areas of risk for health care workers. Each section of checklists is introduced by compelling statistics that show how dangerous working in the healthcare environment can be, without proper precautions. The checklists provide the procedures or must-do activities to ensure that health care workers are as safe as can be.
  18. Content Article
    The National Institute for Health and Clinical Excellence (NICE) guideline covers assessing all chronic pain (chronic primary pain, chronic secondary pain, or both) and managing chronic primary pain in people aged 16 years and over. Chronic primary pain is pain with no clear underlying cause or pain (or its impact) that is out of proportion to any observable injury or disease. Download the full guidance from link below or click on the image for a visual summary. We have also included links to supporting evidence and to useful tools and resources.
  19. Content Article
    Tokophobia is an extreme fear of pregnancy and childbirth; it causes severe psychological distress and can have far reaching consequences. Despite this, tokophobia is under-researched and many healthcare professionals have never heard of it, explains Sarah-Jane Archibald in this BMJ Opinion article.
  20. Content Article
    Government plan to prevent, mitigate and respond to the mental health impacts of the pandemic during 2021 to 2022.
  21. Content Article
    In 2009, the World Health Organization (WHO) published the WHO Surgical Safety Checklist, and 3 years later, the Swiss Patient Safety Foundation adapted it for Switzerland. Several meta-analyses and systematic reviews showed ambiguous results on the effectiveness of surgical checklists. Most of them assume that the study checklists are almost identical, but in fact they are quite heterogeneous due to adaptations to local settings. In this study, Fridrich et al. aims to investigate the extent to which the checklists currently used in Switzerland differ and to discuss the consequences of local adaptations.
  22. Content Article
    The MDU’s Michael Devlin argues in this BMJ Opinion article that the never events policy has had a limited effect on patient safety and welcomes a reassessment by the Healthcare Safety Investigation Branch.
  23. Content Article
    Students learn about medication and non-medication strategies for reducing symptoms of depression and other neuropsychiatric symptoms (e.g. agitation, anxiety) in people with dementia. While non-medication strategies are often emphasised as being preferable, often we lack the time and resources to facilitate their implementation. There is also a sense that people believe that medications worked better—even though we don’t really know if this is true since studies comparing medication to non-medication strategies are rare. The problem with prescribing medications in this patient population is that medications are associated with potentially catastrophic side effects (e.g. falls and fractures). Jennifer Watt and Zahra Goodarzi  undertook a research project looking at the comparative efficacy of interventions for reducing symptoms of depression in people with dementia. Based on their clinical experience as geriatricians, they hypothesised that non-medication strategies could effectively reduce symptoms of depression because they are addressing its underlying causes. 
  24. Content Article
    Abi Rimmer asks four experts whether doctors must be vaccinated against COVID-19 in this BMJ article.
  25. Content Article
    This page from NHS Wales signposts employers and employees to key information and guidance for workplaces which will assist in taking appropriate action upon returning to the workplace, to prevent transmission of COVID-19 and provide relevant sector specific guidance. Documents found on this page will also be particularly useful for employers experiencing clusters of cases that may be associated with their workplace.
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