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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Coroners have a statutory duty to issue a Prevention of Further Deaths report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths.  This is a coroner's report into the death of Susan Warby. The coroner's report concluded that the incorrect intravenous fluid was given and remained in place for approximately 36 hours before it was changed. As a direct result, blood tests on samples drawn from the arterial line gave incorrect results. The incorrect results were exacerbated by the poor technique being used by staff to draw blood from the arterial line transducer set when they failed to fully account for the 'dead space', which needed to be fully removed to obtain an accurate result. These erroneous blood results led to Sue being given doses of insulin medication over a two-day period that she did not need. The incorrect insulin doses caused Sue to suffer from bouts of extremely low blood sugar (hypoglycaemia) which caused her to develop a brain injury of uncertain severity.
  2. Content Article
    Delays in evaluation and escalation of needed care can compromise outcomes of the patient significantly and, in many cases, may lead to death. The assembly of a rapid response team would not only provide timely multidisciplinary evaluation of a potentially deteriorating patient, but it would also help reinforce the organization’s culture of collaboration and interprofessional support for safety. Patients often exhibit signs of deterioration before experiencing the adverse event. The rapid response team’s timeliness in evaluation, coupled with the recommendations from multiple, interprofessional individuals, instead of solely the bedside nurse, would significantly prevent a plethora of adverse events and save financial resources. Specifically, the implementation of rapid response teams has been associated with reductions in cardiac arrests, inpatient deaths, and number of days in the hospital. Many healthcare organisations have successfully implemented and sustained improvements with the advent of rapid response teams. These organizations have focused on projects that included establishing standardized calling criteria for both clinicians and patients and family members, and delineating roles and responsibilities for all upon rapid response team arrival. This Patient Safety Movement Actionable Patient Safety Solutions (APSS) provides a blueprint that outlines the actionable steps organisations should take to successfully implement and sustain rapid response teams and summarises the available evidence-based practice protocols.
  3. Content Article
    The Comprehensive Unit-based Safety Program (CUSP) is a method that can help clinical teams make care safer by combining improved teamwork, clinical best practices, and the science of safety. The Core CUSP toolkit gives clinical teams the training resources and tools to apply the CUSP method and build their capacity to address safety issues. A number of toolkits are available to help clinical teams adopt the CUSP method to make care safer. Most teams will want to start with the Core CUSP Toolkit to learn key principles of the CUSP method. Once you’ve learned the basics, additional toolkits can help you target certain safety issues in specific settings of care. Created for clinicians by clinicians, the Core CUSP toolkit is modular and modifiable to meet individual unit needs. Each module includes teaching tools and resources to support change at the unit level, presented through facilitator notes that take you step by step through the module, presentation slides, tools, and videos.
  4. Content Article
    The Cornwall and Isles of Scilly Safeguarding Adults Review into The Morleigh Group has found elderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated. The Morleigh Group operated seven homes in Cornwall and has since shut down. The review was completed in April 2019 but has only just been made public - Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
  5. Content Article
    In October 2001 government chief nurses and other delegates from 66 countries met to discuss how best to deal with a common challenge—the global growth of nursing shortages. In this article, James Buchan looks at potential solutions and limitations. Although written in 2002, this is still relevant for today.
  6. Content Article
    In this Episode of the 'This Is Nursing' podcast series, Gavin Portier speaks to Amanda McKie, Matron -for Learning Disabilities & Complex Needs Coordinator at Calderdale & Huddersfield NHS Foundation Trust. In this episode Amanda talks about health inequalities, mental capacity, advocacy and high profile key documents such as Death by Indifference, the LeDer Mortality programme and the current case of Oliver McGowan. Learning disabilities is a life long condition and they can present in any areas of health care. In this podcast we discover how important it is to have an understanding an appreciation and insight into the care experience of a person with a learning disability and their parents or carers.
  7. Content Article
    The coronavirus pandemic has magnified a myriad of challenges in the healthcare sector. Whilst there is no magic cure, a change in culture can deliver seemingly miraculous benefits including reducing the effects of staff burnout, delivering a higher quality of care and increasing productivity. It is well within the remit of leaders, who can use their power, to influence workplace culture and drive positive change from within. Phil Taylor of RLDatix explores this further in his blog.
  8. Content Article
    The Patient Safety Authority is an independent state agency that collects reports of patient safety events from Pennsylvania healthcare facilities. Pennsylvania is the only state that requires healthcare facilities to report all incidents of harm (serious events) or potential harm (incidents).
  9. Content Article
    On 30 May 2020, NHS England and the NHS Confederation launched the NHS Race and Health Observatory, a new centre to investigate the impact of race and ethnicity on people’s health and to identify and tackle the specific health challenges facing people of black and ethnic minority origin. 
  10. Content Article
    People with severe food allergies should carry two adrenaline autoinjector pens with them at all times, according to new guidance. Updated advice from The National Institute for Health and Care Excellence (NICE) says healthcare professionals should always offer people with severe allergies a prescription for two adrenaline auto-injectors (AAIs), which deliver potentially life-saving doses of the hormone to treat anaphylaxis, before being discharged from hospital after emergency treatment. They should also advise patients to always carry two devices with them, the guidance states.
  11. Content Article
    This NHS Resolution video looks at three diseases where GPs often miss the diagnostic signs resulting in late referrals: cauda equina, colorectal cancer and subarachnoid haemorrhage. Clinical symptoms to be aware of in these diseases are highlighted.
  12. Content Article
    Venous thromboembolism (VTE) is an international patient safety issue and a clinical priority for the NHS. Around half of all cases of VTE are associated with hospitalisation, with many events occurring up to 90 days after admission. It is a leading and preventable cause of death in an estimated 25,000 of hospitalised patients each year.
  13. Content Article
    One of the areas where Human Factors is getting more traction is within the healthcare sector. It is still a slow burner though with lots more work to be done, and this is getting more urgent as new technologies are available to make procedures and processes better and potentially support more effective patient outcomes. Dr Mark Sujan has taken this challenge head on by launching the Artificial Intelligence and Digital Health Special Interest Group with the CIEHF. In this podcast, we find out more about Mark and his motivations, as well as what his intentions for the Special Interest Group are.
  14. Content Article
    The US National Quality Forum (NQF) convened a multistakeholder committee to identify recommendations for the practical application of the Diagnostic Process and Outcomes domain of the 2017 Diagnostic Quality and Safety Measurement Framework, measuring and reducing diagnostic error, and measuring and improving patient safety. This report outlines the recommendations through a series of four Use Cases – missed subtle clinical findings (Use Case 1), communication failures (Use Case 2), information overload (Use Case 3), and dismissed patients (Use Case 4) – that depict resolutions to specific types of diagnostic errors, and broad-scope, comprehensive recommendations with applications to multiple populations and settings.
  15. Content Article
    Maintaining safe elective surgical activity during the global coronavirus disease 2019 (COVID‐19) pandemic is challenging and it is not clear how COVID‐19 may impact peri‐operative morbidity and mortality in this population. Therefore, adaptations to normal care pathways are required. Here, Kane et al. establish if implementation of a bespoke peri‐operative care bundle for urgent elective surgery during a pandemic surge period can deliver a low COVID‐19‐associated complication profile. Kane et al. present a single‐centre retrospective cohort study from a tertiary care hospital of patients planned for urgent elective surgery during the initial COVID‐19 surge in the UK between 29 March and 12 June 2020.
  16. Content Article
    Healthcare workers and their families account for 17% of hospital admissions for COVID-19 in the working age population (18-65 years), finds new research published in the BMJ. Shah et al. assessed the risk of hospital admission for COVID-19 among patient facing and non-patient facing healthcare workers and their household members. The study revealed that healthcare workers in patient-facing roles were around three times more likely to be hospitalised with the virus than the general population. The authors call for an urgent focus on how COVID-19 spreads around hospitals to prevent a similar toll in future waves of the pandemic. They also call for hospitals to consider re-deploying staff with vulnerable family members away from high-risk zones.
  17. Content Article
    This Healthcare Safety Investigation Branch (HSIB) report charts a four-month patient safety investigation that was launched following concern that patients were contracting COVID-19 after being admitted to hospital. The report references data presented to SAGE in mid-May that suggested around 20% of patients were reporting symptoms seven days after admission. The aim of the investigation was to understand the factors that could contribute to the risk of transmission, how the NHS operates to reduce that risk and where there may be opportunities to reduce that risk even further. The investigation represented the voices of those working across the health service, from strategic national planners to hospital porters. It also captured experiences of patients and families, providing further insight into the challenges of managing the transmission of COVID-19.
  18. Content Article
    Evidence suggests that full implementation of the WHO surgical safety checklist across NHS operating theatres is still proving a challenge for many surgical teams. The aim of the current study from Charles Vincent and colleagues was to assess patients’ views of the checklist, which have yet to be considered and could inform its appropriate use, and influence clinical buy-in.
  19. News Article
    In late July 2019, Sara Ryan tweeted asking families with autistic or learning disabled children to share their experience of “sparkling” actions by health and social care professionals. She was writing a book about how professionals could make a difference in the lives of children and their families. "These tweets generated a visceral feeling in me, in part because of the simplicity of the actions captured. Why would you not ring someone after a particularly difficult appointment to check on them? Isn’t remembering what children like and engaging with their interests an obvious way to generate good relationships? Telling a parent their child has been a pleasure to support is commonplace, surely?" Sara's own son, Connor, was left to drown in an NHS hospital bath while nearby staff finished an online Tesco order. "Certain people, children and adults, in our society are consistently and routinely positioned outside of 'being human', leading to an erasure of love, care and thought by social and healthcare professionals. They become disposable." What has become clear to Sara is how much the treatment of people and their families remains on a failing loop, despite extensive research, legislative and policy change to make their lives better, and potentially transformative moments like the exposure of the Winterbourne View scandal. At the heart of this loop are loving families and a diverse range of allies, surrounded by a large cast of bystanders who, instead of fresh eyes, have vision clouded by ignorance and sometimes prejudice. "To rehumanise society, we need more people with guts and integrity who are prepared to step up and call out poor practice, and to look afresh at how we could do things so much better with a focus on love and brilliance." Read full story Source: The Guardian, 27 October 2020 Sara Ryan's book: Love, learning disabilities and pockets of brilliance: How practitioners can make a difference to the lives of children, families and adults
  20. News Article
    Concerns are growing that long NHS waiting times caused by the coronavirus crisis are exacerbating pre-existing health inequalities and creating a “two-tier” system, as more people turn to the private sector for quicker treatment. As leading doctors warn mass cancellations of NHS operations in England are inevitable this winter after waiting times reached the highest levels on record this summer, data shows a rise in the number of people self-funding treatment or investing in private health insurance. “COVID-19 has not impacted everyone equally, and there is clearly a risk that the backlog in routine hospital treatment is going to add to those inequalities if some people are able to get treatment faster because they’re able to pay,” said Tim Gardner, from the Health Foundation thinktank. As the NHS heads into winter and a growing second wave of the virus, experts stressed the need to help those affected by the backlog now. “There is a need to prioritise the most urgent cases, but simply because someone’s case isn’t urgent doesn’t mean it’s not important. It doesn’t mean that people aren’t waiting in pain and discomfort, or waiting anxiously for a diagnosis,” said Gardner. “We think it’s incumbent on the health service to make the best possible use of the capacity it’s got. But also it needs to make sure it’s supporting people while they’re waiting. We just can’t have people left in limbo.” Read full story Source: The Guardian, 27 October 2020
  21. Content Article
    A new report from Healthwatch and the British Red Cross looks at how well the new hospital discharge policy is working for patients, carers and healthcare professionals. In March 2020, the Government introduced a new hospital discharge policy to help the NHS free up beds by getting people out of hospital quickly. This meant anyone who may need out-of-hospital support to help them recover would now have their needs assessed after being discharged, rather than in hospital.  How has the new policy affected people's experience of leaving hospital? Healthwatch and the British Red Cross spoke to over 500 patients and carers and conducted 47 in-depth interviews with health and care professionals involved in the hospital discharge process.  The research shows significant numbers of people are not receiving follow-up support after being discharged from hospital under new policy, leading to unmet needs. 
  22. Content Article
    This is a book written to celebrate the humanity of people, and to share experiences of what brilliant care and support can look like for families with learning disabled or autistic children and adults. Sara Ryan steers clear of jargon and 'doublespeak' to conjure authentic experiences of families. Speaking with families and professionals, she conveys the love, laughter and joy which binds families and the harsh realities many face; of separation from loved ones, substandard care and frustration and helplessness in the face of inflexible services. From their experiences, Sara looks to capture those pockets of brilliance that families have encountered, and which outstanding practitioners have pioneered, for us all to learn from. We know so much about what support and services should look like in order to enable flourishing lives - this book aims to help families and professionals to achieve it, together.
  23. Content Article
    Nina Hemmings responds to the 'State of the adult social care workforce report' from Skills for Care.
  24. Content Article
    In his latest blog, Steven Shorrock explores what humanistic values and human decency means in management and organisational behaviour. Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives.
  25. Content Article
    Findings from the Healthcare Inspectorate Wales Chief Executive's Annual Report. This report provides an overview of the work undertaken during the past year and what has been found. Healthcare Inspectorate Wales is the independent inspectorate and regulator of healthcare in Wales.
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