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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The World Health Organization (WHO) is actively exploring the role of compassion in quality health care. This Global Health Compassion Rounds (GHCR) highlighted the compelling evidence around compassion and quality care—not only for patients, but also for providers and health care organisations. Respondents offered their views of the implications of this evidence at national, district, and community levels of care. 
  2. Content Article
    A rapid-learning report on the role of Patient Safety Collaboratives (PSCs) during the pandemic has been published by the AHSN Network. PSCs are just one part of the health and care system which responded quickly to the immediate crisis from COVID-19 in March. They reprioritised their day-to-day work and took on new programmes at speed, such as promoting safer tracheostomy care. The report has been published as part of the NHS Reset campaign and gives examples of how PSCs refocused their work ‘almost overnight’ to respond to the pandemic. It illustrates some of the creative ways AHSNs supported their local systems and how this experience will be built into future patient safety programmes.
  3. News Article
    Doctors from black, Asian and minority ethnic backgrounds have been hindered in their search for senior roles because of widespread “racial discrimination” in the NHS, according to a report from the Royal College of Physicians. The RCP, which represents 30,000 of the UK’s hospital doctors, found that ingrained “bias” in the NHS made it much harder for BAME doctors to become a consultant compared with their white counterparts. “It is clear from the results of this survey that racial discrimination is still a major issue within the NHS,” said Dr Andrew Goddard, the RCP’s president. “It’s a travesty that any healthcare appointment would be based on anything other than ability.” Read full story Source: The Guardian, 21 October 2020
  4. Content Article
    Guy's and St Thomas' NHS Foundation Trust share their Quality Impact Assessment (QIA) policy. The QIA policy has been developed to ensure that the Trust has the appropriate steps in place to safeguard quality whilst delivering changes to service delivery. This process is used to assess the impact that the Cost Improvement Plan (CIP) may have on the quality of care provided to patients at Guys and St Thomas’ NHS Foundation Trust.
  5. Content Article
    The CPOC Newsletter is for all doctors, nurses and allied health professionals working in or with an interest in the developments of perioperative care. The monthly publication highlights the most up to date information on the workstreams, partner projects, perioperative events, recently published journals, live surveys and successful perioperative initiatives.
  6. Content Article
    Reports of 'Long-COVID' are rising but little is known about prevalence, risk factors, or whether it is possible to predict a protracted course early in the disease.
  7. News Article
    The Health Secretary is urging the public – and especially young people – to follow the rules and protect themselves and others from COVID-19, as new data and a new film released today reveal the potentially devastating long-term impact of the virus. The symptoms of ‘long COVID’, including fatigue, protracted loss of taste or smell, respiratory and cardiovascular symptoms and mental health problems, are described in a new film being released today as part of the wider national Hands, Face, Space campaign. The film calls on the public to continue to wash their hands, cover their face and make space to control the spread of the virus. The emotive film features the stories of Jade, 22, Jade, 32, Tom, 32 and John, 48, who explain how their lives have been affected – weeks and months after being diagnosed with COVID-19. They discuss symptoms such as breathlessness when walking up the stairs, intermittent fevers and chest pain. The film aims to raise awareness of the long-term impact of COVID-19 as we learn more about the virus. A new study from King’s College London, using data from the COVID Symptom Study App and ZOE, shows one in 20 people with COVID-19 are likely to have symptoms for 8 weeks or more. The study suggests long COVID affects around 10% of 18 to 49 year olds who become unwell with COVID-19. Read full story Source: Gov.uk, 21 October 2020
  8. Content Article
    The work presented here was undertaken by the OECD to provide a strategic background report for the Patient Safety Priority within the G20 Health Working Group (HWG) 2020. It was commissioned by the Saudi Government. ‘"Acting on patient safety requires leadership and communication, political will, and investment. Transparency across a health system is also integral to begin improving safety and reducing harm. This can only be achieved through investing in a modern information infrastructure, but also relies on sound governance, accountability and proactive leadership. The analysis is clear: unsafe care kills millions, and harms tens of millions of people each year. It also exerts a great economic cost on health systems and society, consuming valuable resources that could be put to productive uses elsewhere. Much of this can be prevented through concerted action and adequate investment. The time for action is now."
  9. News Article
    Lockdown had a major impact on the UK's mental health, including increased rates of suicidal thoughts, according to new research. The study, led by the University of Glasgow, examined the effects of COVID-19 during the height of the pandemic. Certain groups are said to be particularly at risk, including young people and women. This publication is the most detailed examination of how the UK's adult population coped during the first weeks of lockdown, when people were given strict orders to stay home. Researchers say public health measures, like lockdowns, are necessary to protect the general population, but warn they may have a "profound and long-lasting" effect on mental health and will extend beyond those who have been affected by the virus. The study, published in the British Journal of Psychiatry, looked at three blocks of time between March 31 and May 11. Just over 3,000 adults in the UK were surveyed and a range of mental health factors were considered, including depression, loneliness, suicide attempts and self-harm. The study found suicidal thoughts increased from 8% to 10% and they were highest among young adults (18-29 years), rising from 12.5% to 14%. The researchers say that, even though those are relatively small rises, they are significant because of the short period of time they happened over. "The majority of people did not report any suicidal thoughts, but this creeping rise over a very short period of time is a concern," says Prof Rory O'Connor, chair in health psychology at the University of Glasgow's Institute of Health and Wellbeing. Read full story Source: BBC News, 21 October 2020
  10. News Article
    A hospital in Yorkshire has said it is cancelling planned surgeries for at least two weeks as the number of coronavirus patients there hits levels not seen since May. Bradford Teaching Hospitals said it was being forced to stop non-urgent surgery and outpatient appointments for two weeks from Tuesday because of the numbers of severely ill COVID-19 patients. In statement the hospital said it had seen a spike in admissions in the last few days with 100 coronavirus patients now on the wards with 30 patients needing oxygen support – the highest number of any hospital in the northeast and Yorkshire region. It also said more patients were needing ventilators to help them breathe in intensive care. The trust is the latest to announce cancellations, joining the University Hospitals of Birmingham, Nottingham University Hospitals and Plymouth Hospitals as well as those in Liverpool and Manchester where hundreds of Covid patients are being looked after. Read full story Source: The Independent, 21 October 2020
  11. News Article
    UK researchers have developed a new risk prediction tool that estimates a person’s chance of hospitalisation and death from COVID-19. The algorithm, which was constructed using data from more than eight million people across England, uses key factors such as age, ethnicity and body mass index to help identify individuals in the UK at risk of developing severe illness. It’s hoped that the risk prediction tool, known as QCOVID, will be used to support public health policy throughout the rest of the pandemic, in shaping decisions over shielding, treatment or vaccine prioritisation. The research, published in The BMJ, was put together by a team of scientists across the UK, and has been praised for the depth and accuracy of its findings. “This study presents robust risk prediction models that could be used to stratify risk in populations for public health purposes in the event of a ‘second wave’ of the pandemic and support shared management of risk,” the researchers say. “We anticipate that the algorithms will be updated regularly as understanding of COVID-19 increases, as more data become available, as behaviour in the population changes, or in response to new policy interventions.” Read full story Source: The Independent, 21 October 2020
  12. Content Article
    Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. This study from MacFadyen et al. reviewd laparoscopic cholecystectomy in the United States from 1989 to 1995. A total of 114,005 cases were analysed and 561 major bile duct injuries (0.50%) and 401 bile leaks from the cystic duct or liver bed (0.38%) were recorded. Based on this review of laparoscopic cholecystectomies, the authors found that the morbidity and mortality rates are similar to open surgery. In addition, the rate of bile duct injuries and leaks is higher than in open cholecystectomy. Furthermore, bile duct injuries can be minimised by lateral retraction of the gallbladder neck and careful dissection of Calot's triangle, the cystic duct-gallbladder junction, and the cystic duct-common bile duct junction.
  13. Content Article
    A report by Fiona Ritchie OBE, Chair on behalf of Oliver’s Independent Panel for NHS England and NHS Improvement, has been published following an investigation into Bristol, North Somerset and South Gloucestershire clinical commissioning group’s Learning Disability Mortality Review (LeDeR) review into the death of Oliver McGowan.
  14. Content Article
    The pandemic has brought human factors issues to prominence. The Chartered Institute of Ergonomics and Human Factors (CIEHF) and its members are responding rapidly to current challenges by providing expert guidance and help wherever it’s needed most. This site gives details and links to new guidance documents developed and published by us and matches human factors expertise to those needing assistance.
  15. Content Article
    With the emergency response to the COVID-19 pandemic disrupting many patients’ access to GP services, the Patients Association investigated what patients felt about their GP’s premises, and whether they would be confident to return to them. 
  16. Content Article
    This Royal College of Nursing (RCN) publication highlights the specific needs of children and young people undergoing day surgery, outlining pre- and post-operative aspects of care and preparation, parental involvement and facilitating discharge. 
  17. Content Article
    Clift et al. have developed a new risk prediction tool that estimates a person’s chance of hospitalisation and death from COVID-19. The algorithm, which was constructed using data from more than eight million people across England, uses key factors such as age, ethnicity and body mass index to help identify individuals in the UK at risk of developing severe illness.
  18. Content Article
    There is little strong evidence relating to the impact of single-room accommodation on healthcare quality and safety. Maben et al. explore the impact of all single rooms on staff and patient experience; safety outcomes; and costs. The study found that staff needed to adapt their working practices significantly and felt unprepared for new ways of working with potentially significant implications for the nature of teamwork in the longer term. Staff preference remained for a mix of single rooms and bays. Patients preferred single rooms.
  19. News Article
    A man who was the last patient to leave Blackpool Victoria Hospital's intensive care unit after being treated for COVID-19 in July has died. Roehl Ribaya spent 60 days in intensive care in the summer but "never recovered" from the long-term effects of the virus. The Filipino aerospace engineer's family said the virus had taken a heavy toll on the 47-year-old even after he was discharged from hospital on 14 August. He had a cardiac arrest on 13 October and was in a coma until he died two days later. His wife, Mrs Ricio-Ribaya, who lives in St Annes in Lancashire, said: "He was never the same. He was so breathless all the time. "Please follow the government's advice so we can stop this virus. We don't want any more to die." Read full story Source: BBC News, 20 October 2020
  20. Content Article
    In this article for Independent Living, Philip Anderson reflects on the significance of touch, and possible impact of COVID-19 for those who are deprived of touch. Philip is an advocate for barrier-free accessibility, equality, and inclusiveness for persons with disabilities. He is involved in several initiatives in the NHS, and with various disability, and accessibility advisory groups.
  21. Content Article
    Since the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the number of cases of coronavirus disease (COVID-19) in the United States has exponentially increased. Identifying and monitoring individuals with COVID-19 and individuals who have been exposed to the disease is critical to prevent transmission. Traditional contact tracing mechanisms are not structured on the scale needed to address this pandemic. As businesses reopen, institutions and agencies not traditionally engaged in disease prevention are being tasked with ensuring public safety. Systems to support organisations facing these new challenges are critically needed. Most currently available symptom trackers use a direct-to-consumer approach and use personal identifiers, which raises privacy concerns. Kassaye et al. developed a monitoring and reporting system for COVID-19 to support institutions conducting monitoring activities without compromising privacy.
  22. News Article
    There is growing distrust for the NHS and government in communities that are of fundamental importance to the national effort to counter covid, according to research by NHSX. People in so-called “hard to reach” communities are faced with stigma and racism due to the covid pandemic but have dwindling trust in the health service, the research found. They are worried about how their personal data will be used by the NHS and other state bodies. They are particularly concerned that their details will be passed on to the police or immigration services. Read full story (paywalled) Source: HSJ, 20 October 2020
  23. News Article
    Parts of the South East saw “striking” levels of excess deaths occurring in people’s homes between July and October. Analysis of official data by HSJ shows the region, which excludes London, had almost 900 excess deaths in the 10 weeks to 2 October (around 10 per 100,000 population), which accounted for almost three-quarters of the national total in that period. Excess deaths means the number taking place above the seasonal average of previous years. Deaths in people’s homes — as opposed to in hospitals or care homes, for example — more than accounted for the total excess. Meanwhile, only 132 of the region’s deaths in this period mentioned COVID-19 on the death certificate. Experts have described the South East numbers as “very striking”, but said it is not immediately clear what was causing it to be such a significant outlier. Possible explanations for excess mortality during the pandemic have included disruptions to normal health services, as well as anxiety among patients about attending hospital or GP surgeries. Read full story (paywalled) Source: HSJ, 20 October 2020
  24. 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 virtual 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 which were introduced in April 2019, providing a national system of medical examiners will be introduced to provide much-needed support for bereaved families and to improve patient safety. Register hub members can receive a 20% discount. Email info@pslhub.org to receive the discount code.
  25. Event
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    This virtual conference from The King's Fund will share practical ideas about transforming work and workplace cultures. It will explore how leadership and teamworking influences people’s work experiences, releasing their full potential to drive improved outcomes for patients and citizens. Discuss with other local health and care leaders how to create compassionate cultures with improved support for staff to make sure that the NHS and social care organisations are good employers and great places to work. Register
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