Jump to content
 View Profile  See their activity

  • Posts

    11,697

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

Everything posted by Patient Safety Learning

  1. News Article
    Covid patients could be left to languish in hospital and block NHS beds amid delays in setting up “hot” care homes dedicated to receiving them, health chiefs have warned. A plan to reduce care home coronavirus outbreaks by setting up “hot homes” to receive infected people discharged from hospital is running late after dozens of councils missed a government deadline to nominate locations. By the end of October every area of England was supposed to have at least one facility approved for Covid-positive discharges, the government pledged last month. It was part of an attempt to prevent a repeat of the spring pandemic, which killed more than 18,000 residents after thousands of patients were discharged into care homes without tests. But as hospital admissions with Covid continue to rise, only 67 out of 151 local authorities have one set up, according to figures from the Care Quality Commission (CQC). NHS Providers, which represents NHS trusts, said the delays were adding to discharge problems, causing increasing patient stays and a growing number of “super-stranded” patients. “While the new discharge requirements are well-intentioned and aimed at protecting the most vulnerable in care homes, the challenge of implementing the changes has created blockages across mental health, acute and community beds,” said Miriam Deakin, the director of policy and strategy at NHS Providers. Read full story Source: The Guardian, 18 November 2020
  2. News Article
    A coroner has urged ministers to revisit plans to make it possible to hold inquests into babies that are stillborn after a baby died due to “excessive force” during an attempted forceps delivery. Senior coroner Caroline Beasley-Murray has written to the Ministry of Justice after she was forced to stop hearing evidence into the death of baby Frederick Terry, known as Freddie, who died under the care of the Mid and South Essex Hospitals Trust on 16 November, last year. An inquest into his death was started in September where Freddie was found to have died after suffering hypovolaemic shock as a result of losing a fifth of his blood when his skull was fractured during a traumatic birth attempt. In a report on the case the coroner said: “Baby Frederick Joseph Terry was delivered by caesarean section, after a failed forceps attempted delivery on 16 November 2019 and death was confirmed after 40 minutes of resuscitation attempts." "The evidence showed that baby Freddie's very serious scalp and brain injuries were sustained during the failed forceps attempted delivery and, but for these, baby Freddie would have survived as a perfectly formed, healthy baby." The coroner said the injuries he sustained implied “an excessive degree of force” in the application of the forceps, which are curved metal instruments that fit around a baby’s head and are designed to help deliver the baby. The inquest had to be stopped from hearing any more evidence because coroners are not able to investigate stillborn babies. As part of her report, the coroner said: “It would have been helpful for there to have been, during the course of the inquest, an exploration, in the course of evidence, of the treatment and care provided to baby Freddie and his parents at the time of delivery. "Currently there is no legislation to cover the holding of a coroner’s inquest into a stillbirth. In March 2019, the Government issued a consultation on coronial investigations of stillbirths It would be helpful for this important topic to be progressed, whatever the ultimate jurisdictional decisions.” Read full story Source: The Independent, 17 November 2020
  3. News Article
    A top teaching hospital has blamed covid measures for a dramatic rise in the number of trolley waits in its accident and emergency department. In October, 111 patients at Cambridge University Hospitals (CUH) Foundation Trust, which runs Addenbrooke’s Hospital, waited more than 12 hours for admission, despite the region’s relatively low covid rates. CUH recorded just nine 12-hour waits in September and 27 in August. It had no 12-hour waits in either June or July this year, and in October 2019, it had only one. The trust also had 761 patients who waited more than four hours from the decision to admit to admission last month, out of a total of 2,998 emergency admissions. CUH director of operations Holly Sutherland said: “We have had to reorganise the hospital to meet infection control requirements and to reduce the risk of covid-19 transmission. With limited side room availability due to the age of our facilities, this has reduced the number of beds in the hospital by around 100 and has impacted on patient flow from the emergency department." “We would like to apologise to anyone affected by this, and to reassure our patients that their safety is our utmost priority and we are doing everything we can to treat them as quickly as possible.” Read full story (paywalled) Source: HSJ, 18 November 2020
  4. News Article
    Lifting lockdown must be handled better this time round to avoid a surge in Covid that could overwhelm the NHS, doctors say. The British Medical Association has published a blueprint for how it thinks England should proceed with any easing. It includes replacing the "rule of six" with a two-households restriction to reduce social mixing and banning travel between different local lockdown tiers. Government has yet to say if or exactly how England will exit on 2 December. It will decide next week, based on whether cases have fallen enough and how much strain hospitals are under. Read full story Source: BBC News, 18 November 2020
  5. News Article
    Expectant mothers are being warned about potentially confusing guidance on consuming caffeine while pregnant, as research suggests energy drinks could have potentially deadly consequences for their babies. A new report by Tommy’s Maternal and Fetal Health Research Centre claims to have established a 27 per cent rise in the risk of stillbirth for each 100mg of caffeine consumed. Researchers compared stillbirths to ongoing pregnancies among 1,000 women across 41 hospitals from 2014 to 2016 as well as interviewing women about their consumption of caffeinated drinks. They adjusted for demographic and behavioural factors, such as age and alcohol consumption, to determine whether stillbirth was linked to caffeine. One in 20 women were found to have increased their caffeine intake while pregnant in spite of evidence some caffeinated drinks put babies lives at risk. However, experts say that calculating precise intake can be difficult, and guidance on limiting caffeine is not consistent The NHS recommends pregnant women keep their daily caffeine intake below 200mg whereas the World Health Organization stipulates 300mg as the safe amount to consume. Tommy’s, a leading baby charity, called for both the NHS and the World Health Organisation to rethink such guidelines, but refused to outline a specific limit - saying it was the NHS and World Health Organisation’s responsibility to decide the recommendations in light of their new study. Professor Alexander Heazell, an author of the study, said: “Caffeine has been in our diets for a long time, and, as with many things we like to eat and drink, large amounts can be harmful – especially during pregnancy. It’s a relatively small risk, so people shouldn’t be worried about the occasional cup of coffee, but it’s a risk this research suggests many aren’t aware of." Read full story Source: The Independent, 18 November 2020
  6. Content Article
    This survey looks at the experiences of people who stayed at least one night in hospital as an inpatient. People were eligible to take part in the survey if they stayed in hospital for at least one night during November 2021 and were aged 16 years or over at the time of their stay.
  7. Content Article
    Today was the Parliamentary launch event of the Surgical Fires Expert Working Group’s report, 'A case for the prevention and management of surgical fires in the UK', which focuses on the prevention of surgical fires in the NHS This report contains important information on surgical fires and their prevention, to be submitted to the Centre for Perioperative Care (CPOC), in order to make the case for its inclusion on their agenda. In the perioperative setting, a fire may cause injury to both the patient and healthcare professionals. Injuries caused by a surgical fire most commonly occur on the head, face, neck and upper chest. The prevention of surgical fires, which can occur on or in a patient while in the operating theatre, is an urgent and serious patient safety issue in UK hospitals.  A Short Life Working Group (SLWG) for the prevention of surgical fires was established in May 2019, following an initial discussion in December 2018 on the issue of surgical fires in the UK. The group of experts from healthcare organisations and bodies across the UK convened four times in 2019 with the aim of compiling this document, in order to recommend surgical fires for a Never Event classification. The group conducted a literature review of best practice and evidence, in the UK and internationally, which informed the development of a number of considerations that could address the issue of surgical fires. This report contains information surrounding the scale of the problem of surgical fires in the UK, in addition to reported experiences of these incidences by both healthcare professionals and patients. It also includes prevention and management materials, and mandatory training that should be consistently delivered to hospital staff, and concludes with recommendations moving forward, in order to ensure the prevention of surgical fires in UK hospitals.
  8. News Article
    Coronavirus cases in the US will spike after Thanksgiving, further stressing health care systems and prompting new restrictions, an emergency physician said Saturday, as states continued to report soaring numbers of new cases, hospitalizations and deaths. Dr. James Phillips, chief of disaster medicine at George Washington University Hospital, told CNN's Erica Hill he is "terrified" about what's going to happen this holiday season. "We're going to see an unprecedented surge of cases following Thanksgiving this year, and if people don't learn from Thanksgiving, we're going to see it after Christmas as well," Phillips said. Already, grim indicators offer a glimpse of what's to come. A little more than a week after the US first topped 100,000 daily infections, it reported a record of more than 184,000 new cases Friday. Hospitalisations also hit a new high – for the fourth consecutive day – with more than 68,500 COVID-19 patients nationwide, according to the COVID Tracking Project. And the country's daily death toll has topped 1,300 at least three times this week. "Things are going to get much, much worse," said Dr. Leana Wen, a CNN medical analyst and former Baltimore Health Commissioner. She expressed concern over the impact on the already-strained health care system when the new cases added in recent days are reflected in hospitalisations. Read full story Source: CNN, 15 November 2020
  9. Event
    until
    Whether you’re an industry or business leader, a human factors practitioner, researcher or academic, the Chartered Institute of Ergonomics & Human Factors showcase the very best that the discipline has to offer at one of the largest gatherings of ergonomists and human factors professionals in the world. Further information and registration
  10. Content Article
    Two decades ago, the Institute of Medicine published To Err Is Human, a landmark report that brought attention to medical error and became a catalyst for the patient safety movement. Around the 10-year anniversary of the report, a number of articles and studies were published that examined the impact of this movement. Nearly all concluded that it was too early to assess whether significant change had taken place. Now, new data indicates efforts after the 20-year anniversary mark have not progressed as expected. It raises vital questions and renewed areas of focus for the healthcare industry. In this article, Coverys, a provider of medical professional liability insurance, looks at the date and the key claim trends.
  11. Content Article
    The minutes from the most recent Liberty Protection Safeguards (LPS) National Steering Group make for interesting reading for all those in the care home sector. We learn from these that the Government has decided that “now is not the right time” to introduce the care home manager role in England that was previously envisioned under LPS. It had recently been confirmed that the public consultation on the draft regulations and Code of Practice for LPS will be taking place in Spring 2021 and implementation of the LPS is some way off, anticipated to be in April 2022. In the meantime Bevan Brittan provide an update for care home providers that gives the sector some clarity at this earlier stage.
  12. Event
    until
    Integration and collaboration are central features of current health care policy. During the Covid-19 pandemic we have seen some great examples of NHS organisations coming together, as well as closer working between health and local government, and health and the voluntary sector. Greater collaboration across health and care organisations will continue to be important as the system begins to recover. This King's Fund programme is designed to equip senior leaders to develop the skills and behaviours associated with a more collaborative style of leadership. It uses current policy developments to inform and test out what will be most helpful in ‘the real world’ of ICS, STPs and place-based working. The programme takes place over six months and will be a combination of virtual and face to face modules. Module one: 20–21 January 2021 (online via Zoom) Module two: 24–25 March 2021 (online via Zoom) Module three: 24–25 May 2021 (London) Module four: 2–3 June 2021 (London) Further information and registration
  13. News Article
    Mothers are being needlessly separated from their babies under strict hospital restrictions introduced to stop the spread of COVID-19, doctors and charities have warned. The measures preventing UK parents from staying with their babies when one or both require hospital treatment are causing trauma and increasing the risk of physical and mental health problems, it is claimed. Some parents of sick babies are also being barred from seeing their child in neonatal units, which is causing distress and preventing bonding. Campaigners have written to the health secretary, Matt Hancock, to raise their concerns. They want hospitals to review these policies urgently and have called for a working group to draw up national standards to meet families’ needs during pregnancy, birth and breastfeeding. Read full story Source: The Guardian, 16 November 2020
  14. News Article
    Labour is demanding new investment for the NHS as part of the government’s spending review next week, after analysis shows hundreds of thousands of patients are waiting for life-changing operations. The party’s shadow health secretary, Jonathan Ashworth, will challenge Matt Hancock in Parliament on today over the latest NHS data, which reveal almost 500,000 patients are waiting for surgery on their hips, knees and other bones. Last week, NHS England published new data showing more than 1.7 million people were waiting longer than the NHS target of 18-weeks for treatment. The target was last met in February 2016. An analysis of NHS England data reveal which specialities have been hardest hit by the growing backlog of operations, which has soared since the first wave of coronavirus caused widespread hospital cancellations earlier this year. There were 4.3 million patients on NHS waiting lists for hospital treatments in September. Labour said this included 477,250 waiting for trauma and orthopaedic surgery, with 252,247 patients waiting over 18 weeks. The next worst specialty was ophthalmology, which treats eye disorders, with 444,828 patients on waiting lists, 233,425 of whom have waited more than 18 weeks. There were six figure waiting lists over 18 weeks for other specialties including gynaecology, urology, general surgery, and ear, nose and throat patients. Read full story Source: 17 November 2020
  15. News Article
    "It's a full-time job that you can't quit. It's a massive burden that you didn't ask for, didn't expect." Diagnosed with type 1 diabetes at the age of 19, Naomi, now 33, says she reached a point where she simply could not handle "the physical or mental challenges of diabetes any more", a condition known as "diabetes burnout". About 250,000 people in England have type 1 diabetes, which means the body cannot produce insulin, the hormone that controls blood sugar levels. It can lead to organ damage, eyesight problems and - in extreme cases - limb amputation. But for many there is also a significant psychological impact of learning to manage the condition. Naomi felt she could no longer bear testing her blood sugar levels many times each day to calculate how much insulin she needed to inject, even though she knew she was risking her long-term health and putting herself in extreme danger, at risk of developing diabetic ketoacidosis (DKA), which can lead to a coma. She became so ill she was admitted to an eating disorder unit even though she was not struggling to eat. The head of the unit, Dr Carla Figueirdo, says of her diabetes patients: "These people are seriously unwell, seriously unwell. They are putting themselves at harm every day of their lives if they don't take their insulin." Naomi's consultant at the Royal Bournemouth Hospital, Dr Helen Partridge, says the psychological impact of a diabetes diagnosis should not be underestimated. The hospital is hosting one of two NHS England pilot projects looking at how to treat type 1 diabetes patients whose chronic illness affects their mental health. NHS England diabetes lead Prof Partha Kar says: "The NHS long-term plan commits strongly on getting mental and physical health together. If we do tackle these two together, it will help improve outcomes." Read full story Source: BBC News, 16 November 2020
  16. News Article
    Hospital food standards are set to be put on a statutory footing, with trusts held to account by the Care Quality Commission, according to the chair of a government-commissioned review. Philip Shelley, who led the review into hospital food following seven patient deaths from listeria last year, told HSJ the incident was an “absolute condemnation” and that trusts must use the review to improve food standards. The review, published last month, also calls for capital investment to refurbish hospital kitchens and replace old and inefficient equipment, which is likely to cost several hundreds of millions of pounds. The government has accepted the recommendations and Mr Shelley will lead a group of experts to oversee the review’s implementation across the NHS during the next three years. Among the review’s recommendations is the “enhanced role” for the CQC when it inspects NHS trusts. The review states there is currently “very little evidence to prove that food and drink standards are being monitored closely enough” and it therefore recommends placing the standards on a statutory footing from which the CQC can hold trusts to account. Read full story (paywalled) Source: HSJ, 17 November 2020
  17. News Article
    Several patients were harmed after leaders at an acute trust failed to act on multiple concerns being raised about a surgeon, documents obtained by HSJ suggest. The documents reveal a catalogue of governance and safety concerns over the trauma and orthopaedics department at University Hospitals of Morecambe Bay Foundation Trust in the last three years. They include an external review which described the process for investigating clinical incidents as akin to “marking your own homework” and found the T&O department at Royal Lancaster Infirmary driven by “internecine squabbles”. It comes as the trust, which is widely known for a patient safety scandal within its maternity department, also faces a major investigation into whistleblowing concerns over its urology services. Read full story (paywalled) Source: HSJ, 17 November 2020
  18. Content Article
    Fires on the operating field are rare events that should never happen, but do. They are dangerous not only to the patient but to the operating room (OR) team members as well. Surgical fires remain a significant enough risk to justify use of a Fire Risk Assessment Score and adherence to the recommendations of the American Society of Anesthesiologists Task Force on Operating Room Fires and those of the Anesthesia Patient Safety Foundation. Here, the Pennsylvania Patient Safety Authority shares key data and statistics, educational tools, multimedia and related links on surgical fires.
  19. Content Article
    Risk assessments are a central component of mental health care. Few national studies have been done in the UK on risk assessment tools used in mental health services. In this study, Graney et al. aimed to examine which suicide risk assessment tools are in use in the UK; establish the views of clinicians, carers, and service users on the use of these tools; and identify how risk assessment tools have been used with mental health patients before suicide.
  20. Content Article
    When the COVID-19 pandemic began, initial descriptions of the symptomology focused on the clinical presentations of patients in the acute, inpatient setting. In the months since, information on how patients with mild disease present has become available along with information on the fairly common occurrence of asymptomatic disease. More recently, data have emerged that some patients continue to experience symptoms related to COVID-19 after the acute phase of infection. There is currently no clearly delineated consensus definition for the condition: terminology has included “long COVID,” “post-COVID syndrome” and “post-acute COVID-19 syndrome". Among the lay public, the phrase “long haulers” is also being used. Here the COVID-19 Real-Time Learning Network review the current literature on post-acute symptoms in patients with COVID-19, using the term “post-acute COVID-19 syndrome".
  21. Content Article
    Party leaders have written an open letter to Boris Johnson asking him to ensure recommendations made by Baroness Cumberlege are put in place. It's more than three months since her review found three treatments - mesh, primodos and sodium valproate - ruined thousands of lives. 
  22. News Article
    A key expansion of services for patients recovering from coronavirus has been delayed by several months, HSJ has learned. In July, NHS England hailed a “ground breaking” new service with the launch of a website with information for patients on how to recover from covid following hospital discharge. It promised a second phase of the service would allow patients to be connected with health professionals for more tailored support, to be launched “later this summer”. But in a memo sent to professional bodies on 30 October, NHSE said the national roll-out was delayed until at least January 2021, with no date confirmed for the launch beyond that. Documents on the website itself said a “first cohort of patients from Leicester will begin to work through the programme” in November, with a further rollout scheduled for early December, followed by a “refresh” in January 2021 and a “full national rollout accessible across the country” at an unspecified date beyond that. The second phase is seen as vital for ensuring that people with covid receive personalised support to help them recover from its debilitating effects, especially as a separate face-to-face rehabilitation programme was scrapped due to costs. Read full story (paywalled) Source: HSJ, 16 November 2020
  23. News Article
    More than three-quarters of midwives think staffing levels in their NHS trust or board are unsafe, according to a survey by the Royal College of Midwives (RCM). The RCM said services were at breaking point, with 42% of midwives reporting that shifts were understaffed and a third saying there were “very significant gaps” in most shifts. Midwives were under enormous pressure and had been “pushed to the edge” by the failure of successive governments to invest in maternity services, said Gill Walton, the chief executive of the RCM. “Maternity staff are exhausted, they’re demoralised and some of them are looking for the door. For the safety of every pregnant woman and every baby, this cannot be allowed to continue,” she said. “Midwives and maternity support workers come into the profession to provide safe, high-quality care. The legacy of underfunding and underinvestment is robbing them of that – and worse still, it’s putting those women and families at risk.” RCM press release Read full story Source: The Guardian, 16 November 2020
  24. News Article
    Eight months after phrases such as “stay at home,” “flatten the curve” and “social distancing” started to become part of our daily vocabulary, people are experiencing a type of burnout experts call COVID-19 fatigue. “By this point, we know people are tired — tired of missing family and friends, tired of not having a routine, of not going into the office,” said Jeanne Marrazzo, M.D., director of the University of Alabama at Birmingham (UAB) Division of Infectious Diseases. “Whatever disruptions to a person’s normal life have occurred, there is no denying the mental, physical and emotional toll people are experiencing. What we’ve learned — and what we keep learning — is how to combat burnout in safe ways that minimize the spread of the virus and enable us to feel some sense of normalcy.” Figuring out how to safely navigate the new normal is more important than ever, explain UAB experts, particularly heading into more vulnerable and trying winter months that present unique challenges. Read full story Source: University of Alabama at Birmingham, USA, 6 November 2020
  25. Content Article
    Jeffrey Siegelman awoke on a Monday morning with a headache. Fever followed, and the next morning could taste nothing. Now, after more than 3 months of living with COVID-19 and the fatigue that has kept him couch-bound, Jeffrey reflects on what it means to be a patient, how an illness ripples through family and community, and how he will use this experience to be a better physician. Here is what he has learned.
×
×
  • Create New...