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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Matt Hancock has called for British people to routinely get tested for the flu, saying covid diagnostic capacity should be kept and used for “everything” once the pandemic dies down. Speaking at the Commons health and social care committee this morning, the health and social care secretary said the nation “must hold on to” the mass diagnostic capacity it has created for coronavirus. Going further, he called for a change in culture to one of “if in doubt, you get a test”, and for a long-term expansion of diagnostics. Mr Hancock said: “Why in Britain do we think it’s acceptable to solider on when you have flu symptoms or a runny nose, and go in [to work] and make everyone ill? “If you have flu-like symptoms you should have a test for it and find out what is wrong with you and stay at home. We are peculiar outliers in soldiering on and going to work and that… culture, that should change.” Read full story (paywalled) Source: HSJ, 24 November 2020
  2. Event
    The NHS is the world’s first health organisation to publish data on avoidable deaths. The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts following the National CQC and NQB guidance, and Department of Health reporting requirements. The conference will also discuss the role of Medical Examiners providing a national system of medical examiners will be introduced to provide much-needed support for bereaved families and patient safety. Further information and to book your place or email nicki@hc-uk.org.uk Follow the conversation on Twitter #CQCDeathsreview We are pleased to offer hub members a 10% discount. Email: info@pslhub.org for the code.
  3. Content Article
    The use of healthcare complaints to improve quality and safety has been limited by a lack of reliable analysis tools and uncertainty about the insights that can be obtained. The Healthcare Complaints Analysis Tool, developed by Alex Gillespie and Tom W. Reader was used to analyse a benchmark national data set, conceptualise a systematic analysis, and identify the added value of complaint data.
  4. Event
    This virtual conference will focus on reducing restrictive interventions in line with national guidance and ensuring adherence to the National NICE Quality Standard on Violence and Aggression. This focus on reducing restrictive practice is particularly important in light of COVID-19 where mental health services have reported spikes in incidents of physical restraint or seclusion on patients, driven by covid-19 restrictions (HSJ 5th June 2020). Further information and to book your place or email kate@hc-uk.org.uk Follow the conversation on Twitter #reducingrestrictivepractice We are pleased to offer hub members a 10% discount. Email: info@pslhub.org for the code.
  5. Event
    This conference focuses on delivering effective consent practice and ensuring adherence to the new 2020 guidance from the General Medical Council. This timely conference will focus on ensuring adherence to The Seven Principles as outlined by the New GMC Guidance. The conference will also update delegates on implications of recent legal developments. Further information and to book your place or email kate@hc-uk.org.uk Follow the conversation on Twitter #Consentpractice We are pleased to offer hub members a 10% discount. Email: info@pslhub.org for the code.
  6. Event
    This National Virtual Summit focuses on delivering a person-centred approach to complaints handling, investigation, resolution and learning. Through national updates, practical case studies and in depth expert sessions the conference aims to improve the effectiveness of complaints handling within your service, and ensure that complaints lead to change and improvements in patient care. The conference will reflect on the challenges and complaints that have resulted from the Covid-19 pandemic. The conference will also update delegates on the Complaint Standards Framework for the NHS which is in consultation and due to be published by the PHSO in early 2021, and will lead to a single developmental pathway for all complaints staff that rightly acknowledges complaint handling as a professional skill. Further information and to book your place or email kate@hc-uk.org.uk Follow the conversation on Twitter #NHSComplaints We are pleased to offer hub members a 10% discount. Email: info@pslhub.org for the code.
  7. Event
    This virtual masterclass, facilitated by Mr Perbinder Grewal, will focus on patient safety and how to setup a proactive safety culture. We will look at what patient safety is and how we can setup and improve the safety culture. We will look at human factors and how we can mitigate some of the common errors. Can we have a system with zero patient safety incidents or errors? Further information and to book your place or email kerry@hc-uk.org.uk We are pleased to offer hub members a 10% discount. Email: info@pslhub.org for the code.
  8. Content Article
    Every month, the NHS in England publishes anonymised data about the drugs prescribed by GPs. But the raw data files are large and unwieldy, with more than 700 million rows. OpenPrescribing.net are making it easier for GPs, managers and everyone to explore - supporting safer, more efficient prescribing. Source: OpenPrescribing.net, EBM DataLab, University of Oxford, 2020
  9. Content Article
    Patient safety is one of the five priorities of the G20 Health Ministers' Declaration. Read the patient safety section of the Declaration below.
  10. Content Article
    Dr. Donna Prosser is joined by Dr John James, a patient safety advocate, and the author of A New, Evidence-Based Estimate of Patient Harms Associated with Hospital Care. The team discusses the meaning of informed consent for clinicians and patients, the steps to a genuine shared decision making dialogue, and the components that should be addressed in the decision making process. Informed consent cannot be separated from the person-centeredness of an organization. While the shared decision making between clinicians and patients and loved ones does require time, attention, and attentiveness to the patient's wishes and goals, it should be a priority for all healthcare organisations.
  11. Content Article Comment
    @Dr Charles Shepherd Thank you for sharing these resources and tips with us. We've added your guide to our Learn library so others can use it: https://www.pslhub.org/learn/coronavirus-covid19/tips/me-association-post-covid-19-fatigue-postlong-covid-19-syndromes-and-post-covid-mecsf-september-2020-r3623/ I've also linked this comment to our community conversation on long covid: Please do share any other resources you have on long covid and also on ME/CFS or if you would like to write a blog on this we'd be happy to post it on the hub.
  12. Community Post
    Some useful resources and advice from Dr Charles Shepherd here (scroll to his comments at the end of the article)
  13. Content Article
    Modern healthcare is burgeoning with patient centred rhetoric where physicians “share power” equally in their interactions with patients. However, how physicians actually conceptualise and manage their power when interacting with patients remains unexamined in the literature. This study from Laura Nimmon and Terese Stenfors-Hayes explored how power is perceived and exerted in the physician-patient encounter from the perspective of experienced physicians. Although the “sharing of power” is an overarching goal of modern patient-centred healthcare, this study highlighted how this concept does not fully capture the complex ways experienced physicians perceive, invoke, and redress power in the clinical encounter. Based on the insights, the authors suggest that physicians learn to enact ethical patient-centered therapeutic communication through reflective, effective, and professional use of power in clinical encounters.
  14. Content Article
    A new toolkit to support GPs to deliver care for patients with hearing loss and aims to encourage deaf patients to access primary care, has been launched. The educational kit, developed by Royal College of GPs (RCGP) in collaboration with the UK’s largest hearing loss charity, RNID and NHS England and Improvement aims to support GPs to consult effectively with deaf patients by offering tips on how to communicate during face to face and remote appointments. It also offers guidelines on how to recognise early symptoms of hearing loss and how to refer patients for a hearing assessment. The project aims to support GPs implement the latest NICE Guidelines, NHS Accessibility Quality Standard and Guidance across the UK. Resources include an Essential Knowledge Update (EKU) Screencast, GPVTS Teaching Powerpoint, Podcasts, Hearing Friendly Practice Charter for your GP Surgery to sign up to, EKU Online E-learning Module, RCGP Accredited Deaf Awareness Online Course, Hearing Friendly Practice Animation Video and much more.
  15. News Article
    The NHS’ current plan for the covid vaccine rollout — dependent on the arrival of supplies — would see the whole adult population able to begin receiving it before the end of January, according to leaked documents seen by HSJ. Under the plan, everyone who wants to would have been vaccinated by early April. NHS England’s draft COVID-19 vaccine deployment programme, seen by HSJ, reveals when each cohort is likely to begin receiving it, based on its plans to create huge capacity across GP-run facilities, “large scale mass vaccination sites”, NHS trusts, and “roving models” for those who cannot travel. It relies on a range of assumptions including that there will be 75% takeup, outside of residential settings like care homes and prisons, where 100% is expected. The plan also relies on supplies, including more than 7 million doses being available in December. It is not clear what impact a delay to this would have on the rollout. With most doses due to be administered between early January and mid March — at a rate of 4-5 million every week — a small delay may not make a huge impact to the overall schedule. The document is dated 13 November and was shared among some senior NHS regional leaders yesterday. Read full story (paywalled) Source: HSJ, 23 November 2020
  16. News Article
    Coronavirus antibodies last at least six months and offer protection against a second infection, a study of healthcare workers suggests. Staff at Oxford University Hospitals were regularly tested both for COVID-19 infections and for antibodies revealing a past infection. The more antibodies people had, the lower their chances of re-infection. A separate study found pre-existing immunity from other coronaviruses also protected against Covid. Infection consultant Dr Katie Jeffery described the Oxford findings as "encouraging news" ahead of forthcoming Covid vaccines. They indicated that having the virus once "provides at least short-term protection" from getting it again, she said. Read full story Source: BBC News, 21 November 2020
  17. News Article
    More than a million patient operations could be delayed because of widespread shortages of anaesthetists in the NHS – with 9 out of every 10 hospitals reporting at least one vacancy. As coronavirus paralysed the NHS earlier this year, more than 140,000 NHS patients have already waited over a year for treatment. The Health Foundation has warned that 4.7 million fewer patients have been referred for treatment because of the impact of coronavirus on NHS services. The Royal College of Anaesthetists (RCOA) told The Independent the scale of the vacancies was getting worse and labelled it a “workforce disaster” that could cost patients’ lives and have a widespread impact on hospital services. Read full story Source: The Independent, 22 November 2020
  18. News Article
    The coronavirus vaccine developed by the University of Oxford is highly effective at stopping people developing COVID-19 symptoms, a large trial shows. Interim data suggests 70% protection, but the researchers say the figure may be as high as 90% by tweaking the dose. The results will be seen as a triumph, but come after Pfizer and Moderna vaccines showed 95% protection. However, the Oxford jab is far cheaper, and is easier to store and get to every corner of the world than the other two. So the vaccine will play a significant role in tackling the pandemic, if it is approved for use by regulators. "The announcement today takes us another step closer to the time when we can use vaccines to bring an end to the devastation caused by [the virus]," said the vaccine's architect, Prof Sarah Gilbert. Read full story Source: BBC News, 23 November 2020
  19. News Article
    A care agency which left people "at risk of avoidable harm" by not ensuring staff had been properly trained has been put into special measures. Stars Social Support, which provides personal care to people living in their own home, was inspected by the Care Quality Commission earlier this year. Inspectors found safe recruitment procedures were not in place to make sure suitable staff were employed. A report following the inspection states that "safe recruitment procedures were not in place to ensure only staff suitable to work in the caring profession were employed." It said people's references had not been followed up after they had been requested, according to the Local Democracy Reporting Service. The report added: "When the disclosure and barring service (DBS) identified concerns, a risk assessment had not been completed to assess staff suitability." Inspectors also found not all staff who provided care had received appropriate training or training updates to ensure they were competent. Read full story Source: BBC News, 21 November 2020
  20. Content Article
    Debriefs (or After Action Reviews) are increasingly used in training and work environments as a means of learning from experience. Tannenbaum and Cerasoli assessed the efficacy of debriefs with a quantitative review and found organisations can improve individual and team performance by approximately 20% to 25% by using properly conducted debriefs.
  21. Content Article
    In recognition of Transgender awareness week, The King's Fund has created this reading list, which pulls together useful articles, reports and online resources on transgender health.
  22. Content Article
    Falls represent a leading cause of preventable injury in hospitals and a frequently reported serious adverse event. Hospitalisation is associated with an increased risk for falls and serious injuries including hip fractures, subdural hematomas, or even death. Multifactorial strategies have been shown to reduce falls in acute care hospitals, but evidence for fall-related injury prevention in hospitals is lacking. Dykes et al. assessed whether a fall-prevention tool kit that engages patients and families in the fall-prevention process throughout hospitalisation is associated with reduced falls and injurious falls. The study found that implementation of a fall-prevention tool kit was associated with a significant reduction in falls and related injuries. A patient–care team partnership appears to be beneficial for prevention of falls and fall-related injuries.
  23. News Article
    Young, low risk patients with ongoing symptoms of COVID-19 had signs of damage to multiple organs four months after initially being infected, a preprint study has suggested. Initial data from 201 patients suggest that almost 70% had impairments in one or more organs four months after their initial symptoms of SARS-CoV-2 infection. The results emerged as the NHS announced plans to establish a network of more than 40 long covid specialist clinics across England this month to help patients with long term symptoms of infection. The prospective Coverscan study examined the impact of long covid (persistent symptoms three months post infection) across multiple organs in low risk people who are relatively young and had no major underlying health problems. The research has not yet been peer reviewed and could not establish a causal link between organ impairment and infection. But the authors said the results had “implications not only for [the] burden of long covid but also public health approaches which have assumed low risk in young people with no comorbidities.” Read full story Source: BMJ, 17 November 2020
  24. News Article
    As more people suffer lasting symptoms from Covid including fatigue, ME patient advocates fear they will get bad advice, Based on current estimates, about 10% of COVID-19 patients develop lasting symptoms, one of the most common being fatigue. The underlying mechanism is still unclear, but possible explanations include reduced oxygen supply to tissues caused by heart or lung damage, or muscle weakness from prolonged bed rest. However, some doctors are increasingly concerned about the overlap between long Covid and another largely virus-triggered illness: “It’s extraordinary how many people have a postviral syndrome that’s very strikingly similar to myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS),” said the US’s top public health official, Dr Anthony Fauci, in July. “They just don’t get back to normal energy or normal feeling of good health.” Like people with ME/CFS, many long-Covid patients report headaches, brain fog, sleep problems, a racing heart, joint and muscle pain and fatigue. Some also experience a relapse of fever, muscle pain and exhaustion, known as “post-exertional malaise”, if they exercise beyond their capabilities. “There are so many similarities between long Covid and ME/CFS it leads me to believe the underlying pathology is probably the same – except that long Covid is presenting as an epidemic, whereas ME/CFS has presented in a very sporadic way, and by no means in such large numbers in such a short space of time,” said Dr William Weir, a consultant in infectious diseases with a special interest in ME. Read full story Source: The Guardian, 19 November 2020
  25. Content Article
    The Patient Safety Movement Foundation is joined by Aryeh Shander, from Ichan School of Medicine at Mount Sinai and Englewood Hospital and Medical Center in this video. There has been a long-standing perception in medicine that blood products can be used without judicious consideration. It is important to recognise that blood is a biological product and, as such, is subject to virus, which can be transmitted from donor to recipient without detection. While there have been improvements in transfusion safety, it is important to recognise the patient's risk and benefit ratio based on their individual circumstance and thoroughly evaluate all alternatives to a transfusion.
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