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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    This video introduces England's 15 Patient Safety Collaboratives (hosted by Academic Health Science Networks) and how they support the NHS Patient Safety Strategy in areas such as COVID-19, managing deteriorating patients, maternal and neonatal safety, medicines safety, mental health and more. Download the slides here
  2. Content Article
    Ransomware attacks against healthcare providers are increasing and puts patient safety at risk. Ransomware attacks can severely affect a healthcare provider's ability to provide care to patients (e.g., diversion of emergency vehicles, cancellation of appointments) delay or prevent a facility's ability
  3. Content Article
    The purpose of this document from the Medicines and Healthcare products Regulatory Agency (MHRA) is to provide information and guidance to all involved with the purchase, management and use of non-invasive blood pressure measurement devices. It reviews the advantages and disadvantages of mercury, aneroid, electronic manual sphygmomanometers and automated blood pressure measuring devices. This should help to ensure the most appropriate technology is selected for use.
  4. Content Article
    Patients are more likely to experience preventable harm during perioperative care than in any other type of healthcare encounter. For several decades, a hallmark of surgical quality and safety has been the use of checklists to prevent errors (eg, wrong site surgery) and assure that key tasks have been or will be performed. There are widely disseminated arguments recommending the use of checklists in healthcare but also recognised limitations. In this editorial, Matthew B. Weinger discusses the use of the checklist and its limitations.
  5. News Article
    Fewer than a quarter of people who develop coronavirus symptoms request a test, new research has suggested. The study into adherence to the UK’s test, trace, and isolate system also found only half of those who had symptoms were fully self-isolating towards the end of January, when the latest data is from. Experts, including from the Public Health England (PHE) behavioural science team at Porton Down in Wiltshire, found that only half of people could identify the main coronavirus symptoms, which include a cough, high temperature and loss of taste or smell. The research – based on responses from more than 53,800 UK adults to surveys across the pandemic – said: “Adherence to each stage of test, trace, and isolate is low but improving slowly.” The most common reasons for not requesting a test were thinking the symptoms were not Covid-related, symptoms had improved or were mild and not having had contact with anyone with Covid-19. Men, younger people and those with young children were less likely to self-isolate, as were those from more working-class backgrounds, people experiencing greater financial hardship, and those working in key sectors. Common reasons for not fully self-isolating included to go to the shops or work, for a medical need other than Covid-19, to care for a vulnerable person, to exercise or meet others, or because symptoms were only mild or got better. Read full story Source: The Independent, 1 April 2021
  6. News Article
    A public inquiry into the infected blood scandal has been told some patients were used as "guinea pigs" at Belfast's Royal Victoria Hospital. The inquiry is looking at how haemophilia patients across the UK were treated with Hepatitis C infected blood or HIV in the 1970s and 1980s. Among the correspondence presented to the inquiry this week was a letter, dated 1988, sent by Dr Elizabeth E Mayne, consultant/director at the Department of Haematology in the Royal Victoria Hospital, to Professor Ludlam at the Royal Infirmary in Scotland. The letter was part of discussions about a potential switch between an NHS product and a commercial product, Profilate Factor 8. Dr Mayne explained that "complications may arise with this product or indeed a safer product may become available". She added: "I am happy for us to try this arrangement as long as the treatment of the children here and the small number of other patients is safeguarded." She concluded "It would be interesting to see the reactions of the patients to this change over and to see if the number of units consumed is reduced." After the letter was read into the record of the inquiry, the chairman, Sir Brian Langstaff, said: "There is also the implicit suggestion there that the patients will not have been asked in advance. "It is going to be given to them and they wait to see what the reaction is." Counsel to the inquiry, Jenni Richards QC, replied "Yes, there doesn't appear to have been an element of choice." Read full story Source: The Independent, 1 April 2021
  7. News Article
    More than one million people in the UK are suffering from signs of Long Covid, the Office for National Statistics has said. This is a significant increase in previous estimates of persistent and debilitating symptoms and follows the January surge in coronavirus infections across the UK. The ONS said a total of 1.1 million people in the UK reported experiencing Long Covid symptoms lasting beyond four weeks after infection with COVID-19 that were not explained any something else. Long Covid can include chronic fatigue, shortness of breath, so called ‘brain fog’ as well as serious organ damage to the kidneys, heart and lungs. The ONS found the symptoms were impacting on the day to day lives of 674,000 people, with almost 200,000 people reporting their ability to carry out normal activities had been severely limited. Of those reporting symptoms, almost 700,000 reported having a Covid infection in the previous three months, but 70,000 said it was over a year since their infection. Read full story Source: The Independent, 1 April 2021
  8. News Article
    A bill has been proposed to enable women who paid for mesh removal surgery to be refunded. Subject to the outcome of the Scottish Parliament election, new legislation will be introduced to allow the Scottish Government to meet the travel, medical and other reasonable expenses of those who had mesh removal surgery outwith NHS Scotland. Currently the law does not allow for such payments to be made from public funds. NHS Scotland is also inviting tenders to allow suitably qualified surgeons to perform free mesh removal, where this surgery is clinically appropriate and where patients wish it to take place outside of NHS Scotland. Health Secretary Jeane Freeman said: “The Scottish Government halted the implantation of transvaginal mesh in 2018, and is committed to keeping this halt in place." “We absolutely recognise the serious distress which may have led to women using their own funds to pay for private surgery. As the Scottish Government does not currently have the legal power to refund these past costs we propose introducing legislation in the next parliament, subject to the outcome of the election." Read full story Source: Scottish Government, 24 March 2021
  9. News Article
    Nurses are a crucial part of care across a wide range of sectors, with patients and other professionals often reliant on their expertise. That’s why the Professional Records Standard Body (PRSB) has been asked to develop a new nursing standard by NHSx for use across all the different health and social care settings. The standard aims to improve quality and safety of care in key nurse-led areas, including care planning. It will reflect best practice and standardise documentation across different nursing settings, to free nurses and give them more time to care. For example, it will standardise information that a district nurse in a care home setting can access and share in the same way as a mental health or hospital nurse, with a focus on the person’s overall wellbeing. Read full story Source: PRSB, 30 March 2021
  10. Content Article
    A 3 minute, plain English video from Dr Jackie Barker of the nine roles public contributors play when they get involved with health organisations, from the BMJ Open paper titled "Developing a typology of the roles public contributors undertake to establish legitimacy: a longitudinal case study of patient and public involvement in a health network".
  11. Content Article
    Frequent external interruptions and lack of collaboration among team members are known to be common barriers in end-of-shift handoffs between physicians in the emergency department. In spite of being the primary location for this crucial and cognitively demanding task, workstations are not designed to limit barriers and support handoffs. The purpose of this study from Joshi et al. was to examine handoff characteristics, actual and perceived interruptions, and perceived collaboration among emergency physicians performing end-of-shift handoffs in physician workstations with varying levels of enclosures—(a) open-plan workstation, (b) enclosed workstation, and (c) semi-open workstation. The study showed positive outcomes experienced by physician working in the enclosed workstation as compared to the open and semi-open workstations.
  12. Content Article
    The COVID-19 pandemic is placing unprecedented pressure on a nursing workforce that is already under considerable mental strain due to an overloaded system. Convergent evidence from the current and previous pandemics indicates that nurses experience the highest levels of psychological distress compared with other health professionals. Nurse leaders face particular challenges in mitigating risk and supporting nursing staff to negotiate moral distress and fatigue during large-scale, sustained crises. This paper from Sriharan et al. aims to (1) synthesise existing literature on COVID-19-related burnout and moral distress among nurses and (2) identify recommendations for nurse leaders to support the psychological needs of nursing staff.
  13. Content Article
    The Remote by Default research study, a collaboration between the Universities of Oxford and Plymouth and the Nuffield Trust, has been exploring how technology can be harnessed to support excellent primary care. Using workshops, interviews, and focus groups of clinicians, service users, and other stakeholders, they have begun to map the multiple interacting influences on the choice of consultation modality.
  14. Content Article
    Dr Helen Simpson, Lisa Shepherd and Dr Steve Kell summarise the guidance and implementation of the steroid emergency card in primary care.
  15. Content Article
    In this BMJ article, Brenda Denzler describes how earlier traumatic experiences of medical treatment continue to have an impact on her to this day and how medical professionals can make patients feel empowered and in control.
  16. News Article
    The system for introducing new medical technologies into the NHS remains complex, crowded, and difficult to manage, according to a new report by the Medical Technology Group (MTG). The paper also calls for innovative treatments with medical devices to be given the same support as new pharmaceutical medicines. Current NHS mechanisms to support the uptake and use of innovative technology are severely limited in scope and are focused on ‘picking winners’ rather than the broad system-wide adoption of new technology, the report states. It points to the Accelerated Access Pathway, for instance, which supports fewer than 10 technologies each year; and the lack of a clear mechanism to support the widespread uptake of innovative products across the NHS. And the absence of a broad, national commissioning policy means patients sometimes miss out on the benefits of established technology due to a regional variation in access. Read full story Source: BBH, 24 March 2021
  17. Content Article
    Patients are commonly given written information, for example in the form of leaflets; however, they often do not retain it and poor literacy is a barrier for many. To address this, working in partnership with a local university, a pre-operative assessment unit designed and developed video animations for patients to illustrate preparation for surgery. The aim was to enhance the accessibility and retention of information to improve patient safety and experience.
  18. News Article
    The European Parliament voted by 95% to support the Stop Cancer at Work campaign’s demands for: Legislative action - not just guidance – now, not next year or the year after. Specifically, the European Commission should include hazardous drugs (hazardous medicinal products or HMPs) in Annex I, and reprotoxins, in the Carcinogens and Mutagens Directive (CMD). This legislative action should be supported by new guidance to ensure that effective prevention measures are put in place and implemented across Europe. The Stop Cancer at Work Campaign believes that the European Commission should now get on with including hazardous drugs, reprotoxins and other improvements to the Carcinogens and Mutagens Directive (CMD) passed by the Parliament without any further delay. Legislation to include hazardous drugs is not only supported by the Parliament but also the majority of the Member States that make up the European Council. As a coalition of essential workers, professionals and cancer patients, the Campaign is demanding action from policymakers and political leaders to stop further preventable deaths. The European Commission’s own research shows that at least 40% of cancer cases are avoidable - but we have yet to see meaningful change and very little on preventing workplace cancer in Europe’s Beating Cancer Plan. The scale of the problem is vast: it is estimated that 100,000 new deaths each year of work related cancer from occupational exposure to hazardous substances, the biggest killer in the EU. The European Commission’s own research shows that at least 40% of cancer cases are avoidable. The protective equipment, safer technology and proper practices are available and not costly but employers are unlikely to universally introduce them unless they are required to do so. The Commission has still not published an independent report which was completed last year and supports legislation to include hazardous drugs (HMPs), in the current revision of the CMD. This would be in combination with, but not replaced by, new non- legislative EU guidance and a regular review of a list of HMPs based on an agreed definition. The independent report is based on a year-long consultation with Member States, experts, professionals, patients, employers and workers in healthcare and justifies and delivers a consensus, impact assessment and blueprint to legislate now and prevent exposure of workers and patients to hazardous drugs which cause cancer and reproductive problems. Source: Stop Cancer at Work, 26 March 2021 European Parliament votes to stop cancer at work and include hazardous drugs and reprotoxins in the Carcinogens and Mutagens Directive (CMD) 25.03.21.docx
  19. Event
    This conference will provide a practical guide to delivering an effective prehabilitation programme, ensuring patients are fit for cancer surgery or treatment. This is even more important in light of the COVID-19 pandemic and lockdowns which have had a negative effect on many individual’s health and fitness levels. The conference will look at optimisation of patients fitness and wellbeing through exercise, nutrition and psychological support. Register
  20. Content Article
    UK guidelines recommend that assessment and monitoring of breathless, unwell, or high risk patients with suspected COVID-19 should include pulse oximetry. Guidance published in January 2021 by the World Health Organization includes a provisional recommendation for “use of pulse oximetry monitoring at home as part of a package of care, including patient and provider education and appropriate follow-up. In this BMJ Practice article, Tricia Greenhalgh and colleagues discuss the remote management of COVID-19 using home pulse oximetry.
  21. News Article
    A CORONER has slammed a hospital trust after a vulnerable patient caught Covid-19 on a ward where beds were not socially distanced. Senior coroner for Brighton and Hove, Veronica Hamilton-Deeley, has sent a rare Regulation 28 report for the prevention of future deaths to the Royal Sussex County Hospital, following the death of 78-year-old Brian Button last October. The grandfather-of-three from Pevensey was admitted to hospital after a fall, but contracted coronavirus on the Catherine James ward within the Acute Respiratory Unit.
  22. Content Article
    Two professionals who treated Jack Adcock before his death were convicted of gross negligence manslaughter, receiving 24-month suspended sentences. His nurse, Isabel Amaro, was erased from the nursing register; but after reviews in the High Court and Court of Appeal, his doctor, Hadiza Bawa-Garba, was merely suspended. Nathan Hodson explores the proposition that nurses are at greater risk of erasure than doctors after gross negligence manslaughter through a close reading of the guidance for medical and nursing tribunals informed by analysis from the High Court and Court of Appeal in the Bawa-Garba cases. 
  23. Content Article
    Brian Button, 78 years old, was admitted to the Royal Sussex County Hospital following a fall but contracted COVID-19 pneumonitis on the Catherine James ward within the Acute Respiratory Unity. Senior coroner for Brighton and Hove, Veronica Hamilton-Deeley, in the coroner's report, said that the ward contained 13 beds and that these beds were not socially distanced. A patient review confirmed this. The Royal Sussex County Hospital has responded.
  24. News Article
    In January, England's only NHS gender clinic for children and young people was rated "inadequate" by the country's health watchdog - the lowest rating, meaning it is performing badly. The findings make for sobering reading with inspectors raising "significant concerns" about the way the Gender Identity Development Service (GIDS) works. Nearly 5,000 children are waiting - sometimes for up to two years - for an appointment, and the management team has been disbanded following the inspection. Now BBC News has had exclusive sight of an external report written in 2015 which recommended GIDS take drastic action. It argued the service was "facing a crisis of capacity" to deal with an ever-increasing demand and strikingly it should "take the courageous and realistic action of capping the numbers of referrals immediately". With Care Quality Commission inspectors recently confirming many of the risks highlighted still remain, some have expressed concern about why neither GIDS, nor NHS England, which has ultimate responsibility for the service, have done more to help the children and young people it cares for. Read full story Source: BBC News, 30 March 2021
  25. News Article
    A witness to an inquiry into deaths at England’s largest mental health trust has been intimidated by “cruel and calculated pressure”, with messages described by the man leading the investigation as “truly shocking”. In a statement at the start of hearings into the quality of care at Southern Health Foundation Trust, inquiry chairman Nigel Pascoe QC said one witness had received threatening telephone calls, messages and emails, which he said were “totally unacceptable, damaging and deeply disturbing”. Mr Pascoe said the inquiry had been told Beth Ford, whose job title at the trust is service user involvement facilitator, had been intimidated by members of the public. Ms Ford, who has autism, was admitted to hospital for her mental health earlier this month as a result of the abuse, but has now returned home. It’s the latest incident to hit the controversial inquiry, which has itself faced fierce criticism from the families of five patients who died between 2011 and 2015. The families have pulled out of the inquiry and accused the investigation and NHS England of bullying them and going back on promises to properly investigate the deaths of their relatives. Maureen Rickman, whose sister Jo Deering died in 2011, told The Independent she didn’t believe any of the main families were involved in intimidating witnesses. Read full story Source: The Independent, 29 March 2021
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