Jump to content
 View Profile  See their activity

  • Posts

    11,589

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

Everything posted by Patient Safety Learning

  1. News Article
    The introduction of weekly covid tests for NHS staff in ‘high risk areas’ will mean other groups missing out or waiting longer, well-placed sources have told HSJ. There is also understood to be a standoff between NHS England and Test and Trace over the regular testing of asymptomatic staff, which was announced for the North of England on Monday. NHS trust labs don’t have enough capacity to test all their staff; and there is not enough spare in “pillar two” commercial labs to carry out hundreds of thousands of additional tests. National bodies are said to be in disagreement over who should do it. NHSE believes they should be provided by T&T, and T&T says NHS labs should expand their capacity to carry them out themselves, HSJ has been told. A senior source involved in the testing programme said there would have to be “trade-offs” for T&T to meet the new NHS demand, with supply having to be cut for others who want tests — mostly the general population, or care home staff. At present the NHS has agreed to carry out 100,000 daily tests by the end of the month, as part of the T&T’s overall 500,000 target. It has been encouraged to do more by T&T, but any expansions may face shortages of equipment and supplies such as reagents, as well as staff and space. Read full story (paywalled) Source: HSJ, 13 October 2020
  2. News Article
    A man in the United States has caught Covid twice, with the second infection becoming far more dangerous than the first, doctors report. The 25-year-old needed hospital treatment after his lungs could not get enough oxygen into his body. Reinfections remain rare and he has now recovered. However, the study in the Lancet Infectious Diseases raises questions about how much immunity can be built up to the virus. The man from Nevada had no known health problems or immune defects that would make him particularly vulnerable to Covid. Scientists say the patient caught coronavirus twice, rather than the original infection becoming dormant and then bouncing back. A comparison of the genetic codes of the virus taken during each bout of symptoms showed they were too distinct to be caused by the same infection. "Our findings signal that a previous infection may not necessarily protect against future infection," said Dr Mark Pandori, from the University of Nevada. "The possibility of reinfections could have significant implications for our understanding of COVID-19 immunity." Read full story Source: BBC News, 13 October 2020
  3. News Article
    All pregnant women have been urged by doctors to get a free flu vaccination this winter to ensure they and their babies are protected. People can get infected with flu and coronavirus at the same time - with Public Health England finding if you get both simultaneously you may get more seriously ill. Researchers previously said those who have been infected with both viruses face a serious increase to their risk of death and warned the public “not to be complacent” in the wake of fears flu could circulate around the country alongside COVID-19. The Royal College of Obstetricians and Gynaecologists (RCOG) and Royal College of Midwives note while getting flu is not a big deal for most people, getting the virus while you are pregnant can be serious for a small proportion of women and their babies. Flu can occasionally lead to stillbirth, maternal death and raise the chances of having a miscarriage. Dr Edward Morris, president of RCOG, said: “We are keen to reassure pregnant women that flu vaccination is safe for women to have at any stage in pregnancy - from the first few weeks right up to their due date, and while breastfeeding." "Over the last 10 years, the flu vaccine has been routinely and safely offered to pregnant women in the UK. The vaccine can also pass some protection to babies, which lasts for the first months of their lives." Read full story Source: The Independent, 12 October 2020
  4. Content Article
    In this article, Life QI looks in more depth at the Institute for Healthcare Improvement’s (IHI) Breakthrough Series Collaborative model, which was first launched in the mid-1990s and has been supporting improvements in healthcare quality ever since. Learning within a collaborative is thought to be one of the most successful methods that leads to quality improvement and system wide change - and the Breakthrough Series Collaborative model is one of these models. Described by the IHI as a ‘Collaborative Model for Achieving Breakthrough Improvement,’ the Breakthrough Series has been designed to help organisations by creating a structure in which interested parties can easily learn from each other and from recognised experts, within specific topic areas where they want to make improvements. The model supports the thinking that: “sound science exists on the basis of which the costs and outcomes of current health care practices can be greatly improved, but much of this science lies fallow and unused in daily work. There is a gap between what we know and what we do.” It is this very gap that the Breakthrough Series Collaborative aims to close by creating short-term ‘learning systems’ and teams built from people from different healthcare settings. This article summaries the Breakthrough Series Collaborative and gives tips and tools on how to create a  Breakthrough Series Collaborative for your organisation. Life QI is the global web platform where tools, people and data come together to make improvement happen.
  5. News Article
    An NHS hospital which has faced repeated criticism by regulators for poor standards of care has been fined £4,000 for failing to assess A&E patients quickly enough. The Shrewsbury and Telford Hospitals Trust has been fined by the Care Quality Commission (CQC) after patients were not triaged within 15 mimutes of arrival in A&E – in breach of conditions set by the regulator last year and a national target. The care of emergency patients at the hospital trust, which is also facing an inquiry into poor maternity care, has been a long running concern for the watchdog which has rated the trust inadequate and put it in special measures in 2018. Earlier this year the CQC’s chief inspector of hospitals, Professor Ted Baker, wrote to NHS England warning of a “worsening picture" at the Midlands hospital and demanding action be taken. The CQC said it had issued the fixed penalty notice to the trust because it failed to comply with national clinical guidance that all children and adults must be assessed within 15 minutes of arrival. It also failed to implement a system that ensured all children who left the emergency department without being seen were followed up. After inspections in April 2019 and November 29 the CQC imposed seven conditions on the hospital over emergency care. The regulator said it was now clear the trust had not stuck to the conditions and had breached them both at Royal Shrewsbury Hospital and Princess Royal Hospital. Professor Baker said: "The trust has not responded satisfactorily to previous enforcement action regarding how quickly patients are assessed upon entering the urgent and emergency department." “We have issued a penalty notice due to the severity of the situation and to ensure the necessary, urgent improvements are made. It is essential that patients are seen in a timely way when they arrive at an emergency department; failure to do so could result in deteriorating health, harm, or even death, which is why national guidelines exist and must be followed." Read full story Source: The Independent, 12 October 2020
  6. Content Article
    A Virtual Clinic was set up at an acute general hospital in the Mid-Essex area with the specific aim to co-ordinate the care of adults diagnosed with intellectual disabilities (ID) coupled with two or more long term conditions. This is one of the National Institute for Health and Care Excellence (NICE) shared learning case studies. NICE has over 800 examples showing how our guidance and standards can improve local health and social care services.
  7. Content Article
    "Cancel everything” has trended as a hashtag during the coronavirus disease 2019 (COVID-19) pandemic, and for good reason. The pandemic has touched virtually every aspect of society, substantially altering, and at its onset halting, the very ways nearly every person in the United States works, learns, lives, and maintains health. The practice of surgery has not been immune, with emergency declarations by many states to suspend elective procedures and office visits in mid-March. While only temporary, this abrupt cessation of surgery has had far-reaching implications that can inform future approaches in the context of both crisis and uncertainty as Meredith et al. reflect on in this JAMA article.
  8. News Article
    East Cheshire faces a serious issue with head and neck cancer, with missed target times and inefficient practices leading to worsening outcomes for patients. That’s prompted officials from the NHS Cheshire Clinical Commissioning Group (CCG) to come up with a plan of action to tackle the problem — but as Cheshire East councillors heard this week, it’s hit a snag. Since 2014, the East Cheshire NHS Trust and Manchester Foundational Trust (MFT) have co-delivered the head and neck cancer pathway. This means that patients are seen by staff at Macclesfield Hospital for diagnostic tests — and if malignant cells are detected, then the patient will be referred on to Wythenshawe for surgery or, if sadly needed, East Cheshire’s own palliative care team for supportive care. In a presentation to CEC’s health scrutiny committee, the CCG said just 10% of patients in the borough were seen at Macclesfield within the 62-day target time in Q3 of 2019/20 — against a desired level of 85%. Simon Goff, chief operating officer of East Cheshire NHS Trust, told the committee: “There is no one stop service - which is where a patient gets diagnostics all on the same day. Biopsies are not always up to the standards required so patients need to have it again. This is a key weakness in the existing service.” The lack of a ‘one stop service’ means there are no on-site pathology services — so samples are taken off-site for testing, and with biopsies needing to be analysed within 24 hours of collection, it results in 39% of all patients having to undergo the procedure again. So what did East Cheshire do about it? The first step was to launch a consultation, with 64 former patients out of roughly 300 eligible providing feedback to the Trust over the summer. The ‘robust’ consultation, saw patients express their desire to ‘know what is going on as soon as possible’, with the ‘issue of travel being outweighed by [the desire for] a quick diagnosis’. Fortunately for health chiefs in Cheshire, there are ‘outstanding’ hospitals surrounding the county — with the Care Quality Commission giving top marks to hospitals in Salford, St Helens, and The Christie in Didsbury. So with East Cheshire’s patients happy to travel a distance in order to gain a quick and accurate diagnosis, and the existing partnership with Manchester’s trust, officials are proposing moving some patients experiencing positive diagnoses and ‘bad news’ cases to MFT sites, such as The Christie or Wythenshawe Hospital. The idea is that ‘neck lump’ patients will be immediately sent to Wythenshawe, with all other patients undergoing initial tests in Macclesfield first before being either sent home with the all clear, or referred on. Biopsies will be done in Wythenshawe, as will ‘breaking bad news’ appointments — where patients are told of a positive cancer diagnosis. Officials say this solution ‘would start to address some of the clinical and performance concerns’ by cutting the average diagnosis wait time from four weeks down to one, reducing the amount of appointments patients need to attend, and allowing for continuity of care throughout treatment. Read full story Source: Knutsford Guardian, 10 October 2020
  9. Content Article
    The Royal College of General Practitioners has put together useful resources for GPs during the coronavirus pandemic.
  10. Content Article
    In this study, Avery et al. estimated the incidence of avoidable significant harm in primary care in England, and describe and classify the associated patient safety incidents and generate suggestions to mitigate risks of ameliorable factors contributing to the incidents. The study found there is likely to be a substantial burden of avoidable significant harm attributable to primary care in England with diagnostic error accounting for most harms. Based on the contributory factors we found, improvements could be made through more effective implementation of existing information technology, enhanced team coordination and communication, and greater personal and informational continuity of care.
  11. Content Article
    Accidents at work and occupational diseases are neither determined by fate nor unavoidable – they always have causes. By building a strong prevention culture, these causes can be eliminated and work related accidents, harm and occupational diseases be prevented. 'Vision Zero' is a transformational approach to prevention that integrates the three dimensions of safety, health and well-being at all levels of work. The International Social Security Association (ISSA) Vision Zero concept is flexible and can be adjusted to the specific safety, health or well-being priorities for prevention in any given context. Thanks to this flexibility, Vision Zero is beneficial to any workplace, enterprise or industry in all regions of the world. 
  12. Content Article
    The Re-Engineered Discharge (Project RED) programme is a nationally recognised best practice centered on delivering a patient-tailored hospital discharge plan demonstrated to reduce all-cause 30-day readmissions and improve safety during care transitions. In this study, Mitchell et al. implemented the RED in 10 hospitals to study the implementation process.
  13. News Article
    Saskatchewan's highest court has ruled in favour of a nurse who was disciplined after she complained on Facebook about the care her grandfather had received in a long-term care facility. In a decision delivered Tuesday, the Saskatchewan Court of Appeal set aside a decision by the province's Registered Nurses Association that found Carolyn Strom guilty of unprofessional conduct. Strom was off-duty when she aired her concerns on Facebook in 2015, a few weeks after her grandfather's death. In her Facebook post, she said staff at St. Joseph's Integrated Health Centre in the town of Macklin, about 225 kilometres west of Saskatoon, needed to do a better job of looking after elderly patients. The lawyer for the Saskatchewan Registered Nurses Association argued that Strom personally attacked an identifiable group without attempting to get all the facts about her grandfather's care. In 2016, she was found guilty of professional misconduct by the Saskatchewan Registered Nurses Association and ordered to pay a $1,000 fine and $25,000 to cover the cost of the tribunal. After the association's decision, she received support from the Saskatchewan Union of Nurses, as well as nurses and civil liberties groups across the country. "Once I understood what this case meant ... once it was past being just about me, I didn't want someone else to have to go through the same thing. Because it's been rough," Strom said. Strom says she continued to fight the decision because she wanted nurses to be able to talk about, and advocate for, better care for family members publicly and in a respectful manner. "You should be able to properly advocate for family members, regardless of whether you're a health-care member." "And I felt that if this decision went wrong, it would actually hurt people who have healthcare members as family members. because they would have to be a little more careful and not express concerns for fear of punishment." Appeal court Justice Brian Barrington-Foote wrote in his decision that Strom's freedom of expression was unjustifiably infringed, and she had a right to criticise the care her grandfather received. The judge ruled that criticism of the healthcare system is in the public interest, and when it comes from front-line workers it can bring positive change. Read full story Source: CBC News, 6 October 2020 .
  14. Content Article
    Led by NHS England and Improvement, the national Maternal and Neonatal Safety Improvement Programme’s (MatNeoSIP) mission is to create and embed the conditions for all staff to improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide a high quality healthcare experience for all women, babies and families across England. Learn more about the West of England's national MatNeoSIP.
  15. Content Article
    Surgical site infections (SSIs) are one of the main sources of healthcare-associated infections (HAIs), which is a leading cause of preventable death in the U.S. While multiple causes of SSIs have been identified, one key source of wound contamination is surgical smoke, which can contain live viruses and bacteria as well as toxic chemicals, particulates and contaminated body fluid in the form of blood and dispersed vapor. Plume serves as a transfer vehicle for these pathogens. A team of bacteriology experts at Biotest Laboratories, Inc. in Brooklyn Park, Minnesota, undertook a project to discover if effective smoke capture and evacuation could limit local dispersal and aerosolization of bacteria. The researchers used porcine tissue embedded with viable bacteria (Serratia marcescens) to determine the extent of viable bacteria present in surgical plume. They developed protocols, performed experiments and tabulated results for three separate experiments. Their tests showed that plume from blended current electrosurgery contained viable bacteria and that placing a suction device near the electrosurgical site reduced the number of aerosolised viable bacteria. The study confirmed that effective smoke capture prevents bacteria in smoke from being aerosolised and significantly reduces contamination of a simulated surgical wound, in this case by as much as 50% to 60% compared to control.
  16. Content Article
    The COVID-19 pandemic clearly illustrates the intersection of structural racism, social risk factors, and health. Data from the Centers for Disease Control and Prevention on COVID-19 infection and mortality rates show high incidences in specific geographic regions. Further investigation within Louisiana revealed that rates of hospitalisation and death in Black patients were twice as high as would be expected on the basis of demographic representation. It has been hypothesised that increased exposure to COVID-19 among Black Americans is attributable to greater representation in service occupations and a greater likelihood of living in inner cities with high population density.
  17. Content Article
    The COVID-19 pandemic provides a stark reminder of the importance of health worker safety. Inadequate personal protection equipment (PPE) has been a problem in many settings and there have been too many examples of health workers becoming infected and dying from COVID-19.The harsh consequences of inequalities have also been laid bare by the pandemic. In countries such as the UK and USA, a disproportionate number of infections and COVID-19 deaths have occurred among Black and ethnic minority communities and people in the lowest socioeconomic groups. But what the COVID-19 pandemic has also made clear is how dependent patient safety is on health worker safety. It is crucial to highlight that there can be no patient safety without health worker safety. As in previous outbreaks of Ebola virus disease, Middle East respiratory syndrome, and severe acute respiratory syndrome, only when health workers are safe can they keep patients safe and provide health systems with stability and resilience.
  18. Content Article
    In this blog for the Guardian, a well respected surgeon tells of the time they were admitted to the intensive care unit of the hospital where they worked following a suicide attempt. The surgeon explains how depression is a lot more common in medicine than realised but how it is still stigmatised, even within the medical profession. Many medical staff often display signs of depression differently to others and keep working right up until they break; work brings comfort from the feelings of hopelessness and worthlessness. Very few have the opportunity to attend counselling, since this would require taking time off work.  "I would be smiling and laughing on the outside, but on the inside was a continuous mantra of self-loathing that kept getting louder. I pushed myself harder, took extra shifts, tried to put my head down and just get through it. One day, I had had enough. The pain had become physical as well as mental, and the idea of having to live any longer was unbearable."
  19. Content Article
    All human activity, along with associated emergent problematic situations and opportunities, is embedded in context. The ‘context’ is, however, a a melange of different contexts. In our attempts at understanding and intervening, rarely do we spend much time trying to understand context, especially as it applies to the current situation, and how history has influenced where we are. Instead, we tend to: a) make assumptions about context, but not make these explicit, resulting in different unspoken and untested assumptions; b) limit contextual analysis to proximal, ‘obvious’ or uncontroversial aspects; or c) jump to a potential solution (or a way to realise an opportunity), shortly followed by planning for this intervention (which has the important function of helping us to feel in control, thus relieving our anxiety – at least temporarily). An approach Steven Shorrock has found useful is to spend time considering contextual influences (e.g., on decision making, at multiple levels of organisations) on problematic situations or potential solutions, more explicitly. He shares this in his latest blog.
  20. Content Article
    The NHS Patient Safety Strategy requires every Trust to have a Patient Safety Specialist: an evolving role with the purpose of ensuring that “systems thinking, human factors and just culture principles are embedded in all patient safety activity”. Patient safety is a big topic, and apart from a general sense of frustration that we don’t seem to be making any progress, there’s little agreement about what the problems are, let alone the solutions. Q member, John Tansley discusses his philosophy of patient safety through four key icons, and reflects on how this can inform and shape the evolving role of Patient Safety Specialists.
  21. News Article
    Less than half of the UK population will get a Covid vaccine with the elderly being top priority - a top advisor has warned. Kate Bingham, who was appointed as the chair of the Vaccine Taskforce back in May has claimed that the public has been “misguided” when it comes to availability of a vaccine. In an interview with the Financial Times, she said the government “needs to vaccinate everyone at risk”. She said: “People keep talking about ‘time to vaccinate the whole population’, but that is misguided." “There’s going to be no vaccination of people under 18. It’s an adult-only vaccine, for people over 50, focusing on health workers and carehome workers and the vulnerable.” Read full story Source: Financial Times, 4 October 2020
  22. Content Article
    Trusts and frontline staff are working flat out to restore those services which were necessarily interrupted to cope with the first peak of the pandemic. NHS Providers' Restoring services: NHS activity tracker highlights detailed examples of the innovations trusts and their staff developing to improve capacity, and respond to unmet demand despite the constraints created by COVID-19, and the need to prepare for additional winter pressures. 
  23. Content Article
    Slow-lane logistics shouldn’t stymie fast-track science, says head of UK government’s Vaccine Taskforce, Kate Bingham, in this Nature article. Kate was appointed chair of the UK Vaccine Taskforce in May. The main job of this Taskforce is to identify, manufacture and develop the most promising pandemic vaccines and deliver them rapidly to the populations that need them. COVID-19 is an opportunity to create a permanent system for supplying vaccines for future pandemics, quickly and safely; this process must become as routine and reliable as crafting the yearly influenza vaccine, says Kate. Time and again, outstanding science has been slowed down by the ‘boring stuff’ — practicalities. That includes delays in manufacturing scale-up and legal approvals slowing pivotal US trials of one of my UK company’s potentially life-saving drugs, or progress hampered by logistics, regulatory disagreements and inadequate data disclosure. Often, the problem is not the science or the clinical trials, but the infrastructure. We must take pains now to make sure this does not stall future pandemic vaccines.
  24. Content Article
    Neurological symptoms are seen in patients with COVID-19 and can persist or re-emerge after clearance of SARS-CoV-2. Recent findings suggest that antibodies to SARS-CoV-2 can cross-react with mammalian proteins. Focusing on neurological symptoms, Kreye et al. discuss whether these cross-reactive antibodies could contribute to COVID-19 disease pathology and to the persistence of symptoms in patients who have cleared the initial viral infection.
  25. Event
    HSJ editor Alastair McLellan will be chairing a webinar on building a healthy and health-creating society – partnerships between the health creators, the NHS and government. Panellists will include Lord Victor Adebowale, chair of the NHS Confederation, Dame Donne Hall, chair of the New local Government Network, Merron Simpson, CEO of New NHS Alliance, Dr Gillian Orrow of Horley, and Lord Nigel Crisp. Register
×
×
  • Create New...