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Patient Safety Learning

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  1. 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.
  2. 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 The research has not yet been peer reviewed and could not establish a causal link between organ impairment and infection.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
  3. 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
  4. 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.
  5. Content Article
    Before the emergence of the novel coronavirus and the subsequent pandemic, the health and care system had a poor track record in adopting digital technologies at scale. However, in response to the pandemic the healthcare system rapidly implemented new tools, many technology-based, to allow healthcare to be delivered when physical contact is not possible. The approach to using digital tools in health care provision is undergoing a substantial and rapid shift. Many of the technologies adopted during the first phase of the pandemic were already well established but not widely implemented; the maturity of the technology enabled the provision of healthcare through remote consultation to be much more prevalent much more quickly. Despite this recent rapid adoption of digital technologies, the health and care system remains at the early stages of digital health, with many tools replicating physical approaches and processes rather than taking advantage of what makes digital different. 
  6. Content Article
    “Just Culture” is a culture in which front-line operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated. Organisations are run by people. In tens of industries – transportation, healthcare, energy, internet, and more – thousands of occupations, and millions of organisations around the world, it is people who make sure that things normally go well. And they nearly always do. But sometimes, things go wrong. Despite our best efforts, incidents, accidents and other unwanted events happen. Following such events, there is a need for support and fairness for those involved and affected, and learning for organisations, industry and society as whole. In the absence of intentional wrongdoing or gross negligence, these obligations should not be threatened by adverse responses either by organisations or States. The Flight Safety Foundation outline their Just Culture Manifesto and invite all who support the principles in this Manifesto to join them, and to help make Just Culture a reality in all countries, industries, and occupations.
  7. Content Article
    Falls in Pennsylvania continue to be one of the biggest contributors to patient harm and the fourth most frequently reported adverse event. Looking more broadly, falls are also a frequent cause of patient harm across the United States and globally. Allen and Wallace conducted a review of the literature to identify international strategies and novel approaches to reduce falls and falls from injury, mainly in healthcare facilities, published in the last decade. The review revealed that while no single country has been able to eradicate patient falls, several had implemented measures showing moderate levels of success. Those struggling with a high incidence of falls may benefit from reviewing and adopting one or more of these innovative techniques.
  8. Content Article
    The collapse of healthcare services round the world, the behaviour of some of the “agencies” enforcing quarantining, and high levels of patient harm during the COVID-19 pandemic, undoubtedly warrant a strong response. We need a new agenda for change if we are to address the current threat to patient centred healthcare and patient safety globally. Kawaldip Sehmi, CEO International Alliance of Patient Organizations, summarises the key messages and actions from the 9th biennial Global Patients Congress 2020, 
  9. News Article
    A drug used to treat rheumatoid arthritis appears to help patients who are admitted to intensive care with the most severe coronavirus infections, researchers say. Tocilizumab, a medicine that dampens down inflammation, improved outcomes for critically ill patients, according to early results from an international trial investigating whether the drug and others like it boost survival rates and reduce the amount of time patients spend in intensive care. The findings have not been peer-reviewed or published in a journal, but if confirmed by more trial data, the drug will be on track to become only the second effective therapy for the sickest Covid patients, following positive results for the steroid dexamethasone earlier this year. “We think these are very exciting results, we are encouraged by them,” said Prof Anthony Gordon, of Imperial College London, the UK’s chief investigator on the REMAP-CAP trial. “It could become the standard of care once we have all the data reviewed by guidelines groups, and also drug regulators.” Read full story Source: The Guardian, 20 November 2020
  10. News Article
    People aged 50 to 64 in England will be able to get a free flu jab from 1 December in an attempt to fight the "twin threats" of flu and COVID-19. The group has been added to a list of people who are already eligible for a flu jab in England, such as those over 65 and health and social care workers. Thirty million people are being offered the vaccine in England's largest flu-immunisation programme to date. Health Secretary Matt Hancock said it was a winter "like no other". "We have to worry about the twin threats of flu and COVID-19," he said, adding that the coronavirus pandemic meant it was "more important than ever" that people got their flu jabs. Mr Hancock told BBC Breakfast that all over 50s would be able to get the vaccine by January. Read full story Source: BBC News, 20 November 2020
  11. News Article
    The NHS is going into this winter with 5,500 fewer general acute beds than last year, NHS England data has revealed. The numbers of general and acute beds open overnight from July to September this year was 94,787 compared with 100,370 for the same period in 2019, a fall of 5.6% or 5,583 beds. The reduction in bed numbers is thought to be partly because of covid infection control measures, such as creating more distance between beds. HSJ reported this week that Cambridge University Hospitals Foundation Trust had taken nearly 100 beds out of use to allow for better social distancing. The figures showed significant regional differences. London had 8% fewer beds available compared with last year, while the East of England and the North East only had 3.4% fewer. The North West, which has been badly affected by the second wave of covid, had 6.6% fewer beds than last year. NHS Providers deputy chief executive Saffron Cordery said: “We have been arguing for some time that the NHS is short of beds as we head into winter… This is a real problem as trusts deal with pressures posed by the virus, growing demand for urgent and emergency care and the work to recover the backlog of routine operations.” Nuffield Trust deputy director of research Sarah Scobie said: “This drop in the number of beds available bears out our warning that infection control will mean a loss of capacity even between waves of the virus. Many of these will have been beds too close to others for physical distancing. This is why it will be so difficult to return to previous rates of activity while the virus remains at large, worsening waiting times and forcing difficult decisions about who gets priority." Read full story (paywalled) Source: HSJ, 19 November 2020
  12. News Article
    Death rates for a major emergency abdominal surgery are almost eight times higher at some outlier hospitals compared with top performers, a national report has found. A review of emergency laparotomies in England and Wales has identified six hospitals as having much higher-than-average 30-day mortality rates for the surgery between December 2018 and November 2019. Hospitals identified by the annual National Emergency Laparotomy Audit as having the best outcomes, such as Stepping Hill Hospital and Salford Royal Hospital, had mortality rates of around 2.5%. But the review, published this month, found some hospitals, such as George Eliot Hospital, had 30-day mortality rates for emergency laparotomies as high as 19.6% The national 30-day mortality rate for emergency laparotomies in England and Wales was 9.3% last year and has fallen consistently since the review started in 2013. Some trusts told HSJ that data collection issues were partly to blame for the high mortality rates recorded in the review. Read full story (paywalled) Source: HSJ, 20 November 2020 .
  13. Content Article
    Dr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, interviews Robyn Begley, Chief Executive Officer, American Organization for Nursing Leadership (AONL), and Senior Vice President and Chief Nursing Officer, AHA, around her most recent discoveries in the COVID-19 pandemic. The team conducted a study with over 1,800 participants, ranging from nursing staff to hospital administrators, on the effects of COVID-19 and the challenges and fallbacks that occurred during three periods of the pandemic. After discussion of results, recommendations are proposed for supporting hospitals and healthcare workers.
  14. Content Article
    Losing your sense of smell or having it 'disturbed' is not as rare as you might think: one in 20 people experience it at some point in their lives. It can happen as a result of chronic sinusitis, damage caused by cold viruses, or even a head injury. It is sometimes also a precursor of nervous system diseases such as Parkinson’s and Alzheimer’s. But compared with hearing and sight loss, it receives little research or medical attention. Carl Philpott, Professor of Rhinology and Olfactory at the University of East Anglia, wanted to better understand the issues people with smell disorders face, so him and his team analysed written, personal accounts of anosmia (loss of sense of smell) by 71 sufferers. The texts revealed several themes, including feelings of isolation, relationship difficulties, impact on physical health and the difficulty and cost of seeking help. Many people also commented on the negative attitude from doctors about smell loss, and how they found it difficult to get advice and treatment for their condition.
  15. Content Article
    The Center for Outcomes and Patient Safety in Surgery (COMPASS) in the USA combines clinical collaboration and data to ensure, amongst all surgical and procedural colleagues, the safest, most appropriate and effective and highest quality procedure for every patient, every time. It aims to continuously strengthen the care that our patients receive through the measurement and analysis of surgical outcomes and data. COMPASS is composed of clinicians representing all Massachusetts General Hospital surgical specialties.
  16. Content Article
    Harm reviews give assurance to patients, patient groups, commissioners and the public as to whether patients have been harmed, or are at risk of harm, as well as helping to avoid future harm to patient. Patients may be harmed not only by clinical treatment, but also as a result of the need to be on a waiting list for clinical treatment, as this may result in deterioration of their physical or mental condition.  Royal Cornwall Hospitals standard operating procedure (SOP) identifies a standardised approach to harm reviews for all specialities at the Trust that support the Trusts' governance and assurance processes and maintains practice in line with national expectations.
  17. Content Article
    The Berwick report asks the NHS to change its culture and continuously improve patient safety, but this is not always easy. It takes Herculean will-power from right-minded leaders, constant coaching of the middle managers and it takes time. In this Health Foundation article, Stephen Singleton, a former NHS medical director and Chief Executive, and a former member of the Don Berwick advisory group, asks is it the sheer hardness of the challenge that allows us to tolerate doctors and nurses who are poor role models, incompetent managers and bullies? Or is it something else?
  18. Event
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    The advancing mental health equalities strategy published in September 2020 outlines the core enabling actions NHS England and NHS Improvement will take with the support of the Advancing Mental Health Equalities Taskforce – an alliance of sector experts, including patients and carers, who are committed to creating more equitable access, experience and outcomes in mental health services in England. It sits alongside the NHS Mental Health Implementation Plan 2019/20–2023/24 and as such is similarly focused in scope. This strategy is also an important element of the overall NHS plans to accelerate action to address health inequalities in the next stage of responding to COVID-19. This webinar lead by Dr Jacqui Dyer MBE will introduce advancing mental health equalities strategy and summarise the core actions that NHS England and NHS Improvement will take to bridge the gaps for communities fairing worse than others in mental health services. Register
  19. Content Article
    In this blog, Patient Safety Learning reflects on the recent steps taken by the healthcare system in the UK to increase provision and support for people living with Long COVID. It then goes on to consider the importance of engagement and information sharing with patients, outlining suggestions where Patient Safety Learning feel the current NHS approach could be improved. 
  20. Content Article
    SSKIN is a five step approach to preventing and treating pressure ulcers. Wirral University Teaching Hospital is sharing their version of the SSKIN bundle as part of Stop The Pressure Day. They have worked with their Allied Health Professional colleagues on refreshing the bundle for local use.
  21. News Article
    PRESS RELEASE (London, UK, 19 November 2020) – The charity Patient Safety Learning and the Royal College of GPs have published new guidance to help patients with post COVID-19 syndrome (also known as Long COVID) understand the support they can expect from their GP. This guidance draws on the RCGP's recent summary and top tips for GPs caring for patients with post COVID-19 syndrome. Both these documents have been produced in advance of more detailed national guidance being developed by the National Institute of Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network (SIGN) and the Royal College of GPs, due to be published in December 2020. Helen Hughes, Chief Executive of Patient Safety Learning, said: “We have used the RCGP’s guidance to produce a simple patient-friendly guide to help support people living with Long COVID in the interim period before more detailed guidance is produced by NICE. We hope that this guidance will empower and inform patients, providing them with an evidence-based document that can be shared with those around them. We believe that this will also help raise awareness of the health challenges these patients are facing so that their health and recovery needs can be better met.” Professor Martin Marshall, Chair of the Royal College of GPs, said: “It’s important that patients experiencing debilitating prolonged effects of Covid-19, which we know affect a small but significant number of people who have had the virus, feel that they have the understanding and support of the GPs and other healthcare professionals delivering their care. To this end we hope this guidance is helpful for them. The RCGP is working hard to ensure that the long term effects of Covid-19 are recognised, especially in those who were never admitted to hospital, and that our GP members have interim guidance whilst waiting for formal national guidance, currently being developed by NICE, SIGN and the College, to be published.” Notes to editors: 1. The new Patient Safety Learning and RCGP guidance can be found here: Post COVID-19 syndrome: What support can patients expect from their GP? 2. Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. We believe patient safety is not just another priority; it is a core purpose of health and social care. Patient safety should not be negotiable. 3. The RCGP guidance for GPs can be found here: RCGP, Management of the long term effects of COVID-19. The RCGP response and top tips for caring for our patients, V1 30 October 2020.
  22. News Article
    An Essex maternity department has been served with further warnings by the Care Quality Commission (CQC) and again rated “inadequate”. Serious concerns were raised about the services at Basildon University Hospital in the summer, after several babies were found to have been starved of oxygen and put at risk of permanent brain damage. Despite the CQC issuing warning notices to Mid and South Essex Foundation Trust in June 2020, a subsequent visit on 18 September found multiple problems had persisted. The CQC’s findings at Basildon included: the service was short-staffed and concerns were not escalated appropriately multidisciplinary team working was “dysfunctional”, which sometimes led to safety incidents doctors, midwives and other professionals did not support each other to provide good care. Read full story (paywalled) Source: HSJ, 19 November 2020
  23. News Article
    A hospital trust in Bristol has been accused of risking lives after raising its patient-to-nurse ward ratio to dangerously high levels, having allegedly dismissed staff concerns and national guidance on safe staffing. University Hospitals Bristol and Weston NHS Foundation Trust (UHBW) has introduced a blanket policy across its hospitals that assigns one nurse to 10 patients (1:10) for all general adult wards. This ratio, which previously stood at 1:6 or 1:8 depending on the ward, rises to 1:12 for nights shifts. The new policy, which is applicable to Bristol Royal Infirmary (BRI) and Weston General Hospital, also extends to all specialist high-care wards, which treat patients with life-threatening conditions such as epilepsy and anaphylaxis. Nurses at the trust have expressed their anger over the decision, saying they were never fully consulted by senior officials. Many are fearful that patient safety will be compromised as the second coronavirus wave intensifies, culminating in the unnecessary loss of life. “Patients who would have extra nursing staff because they are very acutely unwell and need close observation I think are going to unnecessarily die,” one nurse at BRI told The Independent. “Or if they survive, they’ll suffer long-term conditions because things were missed as they don’t have the staff at their bed side to watch the deterioration.” Read full story Source: The Independent, 18 November 2020
  24. Content Article
    It is estimated that across the UK, a third of healthcare improvement projects never spread beyond their particular unit, a further third are embedded across their organisation but never spread further than that, and only the final third are spread across their own and other similar organisations. Successfully spreading improvements and ensuring changes are sustained requires overcoming numerous challenges, such as: Creating an awareness of why the change is needed Ensuring those involved have a desire to support and participate in the change Knowledge of how to bring about change The skills and resources to bring about the change Ensuring processes to sustain the change This new guide from the West of England AHSN sets out suggestions to be considered for the successful adoption and spread of innovation and improvement projects.
  25. Content Article
    The Professional Record Standards Body (PRSB) has published a new report on lessons learned from the pandemic to support the future of digital change in health and care. Following a consultation process with 100 of its members, PRSB has published the report examining the digital transformation of services during the pandemic and it recommends how the system can use the lessons in the future.  The Digital Health and Care and COVID-19 report recommendations include building on the enthusiasm for digital but reviewing and evaluating safety implications, particularly for remote and virtual consultation where both clinical risk and patient access need to be addressed. The report also includes a focus on quality in practice, including the use of apps and other digital technologies. 
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