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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    One year ago, on 2 October 2019, we officially launched the hub at our annual conference. To celebrate this special occasion, we want to update you on how the hub has grown and the impact it’s having, both on the people using it directly and on patient safety more broadly. To date, the hub has over 1,000 members from 450 organisations and from over 40 countries. It’s home to over 3,000 pieces of content, has had 45,000 unique visitors and has been accessed 70,000 times. Although we are delighted with these numbers and continued growth of the hub, we are most proud of the relationships the hub is facilitating and the good work that is happening as a result. We launched the hub so that all members of the public – from patients to clinicians – could share their insight and experiences of patient safety. By working together with users of the hub, we aim to highlight patient safety concerns and take action so that real change can happen as we journey towards the patient-safe future.   Wonderfully, we are beginning to achieve these aims. Here are some of the ways the hub has been making an impact.
  2. Content Article
    One year ago, on 2 October 2019, we officially launched the hub at our annual conference. To date, the hub has over 1,000 members from 450 organisations and from over 30 countries. It’s home to 3,000 pieces of content, has had 45,000 unique visitors and has been accessed 70,000 times. Although we are delighted with these numbers and continued growth of the hub, we are most proud of the relationships the hub is facilitating and the good work that is happening as a result. We launched the hub so that all members of the public – from patients to clinicians – could share their insight and experiences of patient safety. By working together with users of the hub, we aim to highlight patient safety concerns and take action so that real change can happen as we journey towards the patient-safe future. Wonderfully, we are beginning to achieve these aims.
  3. News Article
    As she lay dying in a Joliette, Que., hospital bed, an Atikamekw woman clicked her phone on and broadcast a Facebook Live video appearing to show her being insulted and sworn at by hospital staff. Joyce Echaquan's death on Monday prompted an immediate outcry from her home community of Manawan, about 250 kilometres north of Montreal, and has spurred unusually quick and decisive action on the part of the provincial government. The mother of seven's death will be the subject of a coroner's inquiry and an administrative probe, the Quebec government said today. A nurse who was involved in her treatment has been dismissed. But that dismissal doesn't ease the pain of Echaquan's husband, Carol Dubé, whose voice trembled with emotion as he told Radio-Canada his wife went to the hospital with a stomach ache on Saturday and "two days later, she died." Echaquan's relatives told Radio-Canada she had a history of heart problems and felt she was being given too much morphine. In the video viewed by CBC News, the 37-year-old is heard screaming in distress and repeatedly calling for help. Eventually, her video picks up the voices of staff members. One hospital staff member tells her, "You're stupid as hell." Another is heard saying Echaquan made bad life choices and asking her what her children would say if they saw her in that state. Dubé said it's clear hospital staff were degrading his wife and he doesn't understand how something like this could happen in 2020. Read full story Source: CBC News, 29 September 2020
  4. Content Article
    This review explores the benefits of multidisciplinary team working to support people having surgery and the factors that may help and hinder its development and sustainability. Perioperative care is the integrated multidisciplinary care of patients from the moment surgery is contemplated through to full recovery. Multidisciplinary working, whereby professionals from different specialties and sectors work together to support someone along their journey, is a foundation of perioperative care. The Centre for Perioperative Care (CPOC) wanted to explore the benefits of, and barriers and enabler to, multidisciplinary team working. The rapid review summarises learning from 236 UK and international studies about this. About 13% of the studies were from the UK. To identify relevant research, 14 bibliographic databases were searched and screened more than 18,000 articles available as of June 2020.  
  5. Content Article
    In this Episode of the 'This Is Nursing' podcast series, Gavin Portier speaks to Stacey Ward, Capsule Endoscopy Clinical Nurse Specialist from Barnsley Hospital. Capsule Endoscopy is a non invasive way to look inside a patient. Stacey has pioneered a nurse led endoscopy service that she is deeply proud and passionate about. Her vision and drive for the service and improvement to the patient experience and journey is inspiring.
  6. Content Article
    The Care Quality Commission (CQC) insight reports are designed to help everyone involved in health and social care to work together to learn from the COVID-19 pandemic. This report looks at infection prevention and control and provider collaboration reviews.
  7. Content Article
    The Centre for Perioperative Care (CPOC) has now published, perhaps for the first time on this scale, comprehensive evidence that the perioperative pathway is associated with higher quality clinical outcomes, reduced financial cost and better satisfaction for surgical patients. This triad is the holy grail of healthcare. Dr David Selwyn, Director of the Centre for Perioperative Care, and Mr Mark Weiss, Head of Policy and Public Affairs, Royal College of Anaesthetists have written this blog in line with CPOC's own rapid research review that highlights the impact of perioperative care and their pioneering new evidence. "Now is the time to ensure that every surgical patient’s journey is delivered along a single, coordinated care pathway, supported by an appropriate multi-professional team. Now is the time to deliver seamless communication and collaboration between primary, secondary and community care. Now is the time to review our patient flows and how we counsel and prepare patients for surgery. And now is the time to empower patients through shared decision-making and personalised care, and to change the postoperative course with emphasis on enhanced recovery. "
  8. Content Article
    Pressure injuries are a recognized patient safety concern and meet the definition of a reportable event under the Pennsylvania Medical Care Availability and Reduction of Error (MCARE) Act. The Patient Safety Authority has collated guidelines, tools and resources on pressure injuries.
  9. News Article
    Nearly half of trust chairs fail to “effectively deal with non-performing board members” according to a major study of the role of NHS non-executive directors seen by HSJ. The Henley Business School conducted in-depth research over a two-year period for its report 'The Independent Director in Society: Our Current Crisis of Governance & What to Do About It' which is published later this month. The research included a survey of NHS non-executive directors, which reveals that they have a broadly positive view about their contribution but also reveals significant areas of concern. Only 55% of respondents agreed with the statement that NHS trust chairs “effectively deal with/remove non-performing and/or disruptive board members”. Just 47% said chairs had “positive relations with the media.” The survey was undertaken before the onset of the pandemic, but nearly a third of the respondents disagreed with the statement that NHS chairs were “effective in a crisis”. However, almost every survey respondent claimed trust chairs had “high moral values” which were “aligned with those of the organisation.” All but 2% of respondents backed the idea that non-executive directors “have a sense of duty to see things are done both ethically and morally”, while 94% claimed they were “truly independent”. However, a fifth claimed it was impossible for non-executive directors to be effective “given the mandate of the NHS”. Read full story (paywalled) Source: HSJ, 1 October 2020
  10. Content Article
    The objective of this review from Alani et al. is to draw attention to the risk factors, causes and prevention of surgical fires in facial plastic and reconstructive surgery performed under local anaesthesia and sedation using a review of the literature.
  11. Event
    until
    A digital event showcasing how Northern Ireland is collaborating throughout Europe to improve medicines use. To register email: moic@northerntrust.hscni.net
  12. Content Article
    Safety governance refers to the approaches taken to minimise the risk for patient harm across an entity or system. It typically comprises steering and rule-making functions such as policies, regulations and standards. To date, governance has focused on the clinical level and the hospital setting, with limited oversight and control over safety in other parts of the health system. All 25 countries that responded to a 2019 OECD Survey of Patient Safety Governance have enacted legislation that aims to promote patient safety. These practices include external accreditation and inspections of safety processes and outcomes. Safety governance models are also moving away from punishment and shaming towards increased trust and openness. Learning from success as well as failures represents a paradigm shift in safety governance, an approach that has been increasingly adopted in OECD countries.
  13. Content Article
    Patient Led Research for COVID-19 invite you to participate in this research study if you have previously experienced or you are currently experiencing symptoms consistent with COVID-19 as a result of suspected or confirmed SARS-CoV-2 infection. The aim of this research study, sponsored by University College London (UCL), is to better describe and understand the patient experience and recovery of those with confirmed or suspected COVID-19, with a specific emphasis on the Long COVID experience. The focus of this study includes participants’ backgrounds, testing, symptoms, and psychological wellbeing. A secondary aim of this study is to publish patient-driven data in order to advocate for the Long COVID population within the medical community. Patient Led Research for COVID-19 are a self-organised group of COVID-19 long-haul patients working on patient-led research around the COVID experience and prolonged recoveries. They are all researchers in relevant fields – participatory design, neuroscience, public policy, data collection and analysis, human-centered design, health activism – in addition to having intimate knowledge of COVID-19.
  14. Content Article
    The Association of Personal Injury Lawyers (APIL) has been fighting for the rights of injured people for almost 30 years. A not-for-profit campaign organisation, APIL’s 3,200 member lawyers (mainly solicitors, barristers and legal executives) are dedicated to protecting and enhancing access to justice, improving the services provided for victims of personal injury, and campaigning to change the law wherever appropriate. Here is their strategic plan for the next 3 years. In creating this plan, APiL have tried to focus on the big challenges facing people injured due to the negligence of others as they try to rebuild their lives.
  15. Content Article
    The COVID 19 pandemic has been testing the resilience of healthcare workers around the globe. With increased patient loads, the constant threat of getting infected, and ordeal of treating the critically ill, there have been increased burnouts and mental health issues. The safety of Healthcare workers is, therefore, a real concern that needs to be addressed carefully and decisively. Neesha Nair and Ihab Alawour from the Aster Sanad Hospital reflect on how lessons from the MERS-COV epidemics in Saudi Arabia helped them plan for the emerging coronavirus crisis. They use the Systems Engineering Initiative for Patient Safety (SEIPS) framework which places healthcare workers at the centre of the work system. All other system components like healthcare work tasks, technologies and tools, environmental factors, and organisational conditions, serve to enable the healthcare worker to perform their role and determine the quality of the outcomes, may it be job effectiveness or occupational health and safety.
  16. Event
    Join Dr. Timothy R Clark at 12:00 PM EST to learn how to avoid the gutters of paternalism and exploitation. Webinar agenda: The 4 stages of psychological safety. Psychological safety as a function of respect & permission. Failure pattern #1: Paternalism: High respect & low permission. Failure pattern #2: Exploitation: Low respect & high permission. Climbing the ladder of vulnerability with your team. Registration
  17. News Article
    General practices will struggle to cope with a second wave of COVID-19 unless urgent measures are put in place to support them, the BMA has warned. It said that practices in England were reporting that they did not have the capacity to carry out all of the work required of them while managing ongoing patient care, dealing with the backlog of care put on hold during the first wave of the pandemic, and reconfiguring services. Richard Vautrey, chair of the BMA’s General Practitioners Committee England, said, “GPs, like all doctors, are extremely concerned that without decisive action now services will be overwhelmed if we see another spike in the coming weeks and months.” In the report, the committee called for a package of measures to support the GP workforce, including making occupational health services available to all staff to ensure that they are properly risk assessed and to provide free supplies of personal protective equipment. It also called for the suspension of routine inspections by the Care Quality Commission and of the Quality and Outcomes Framework, as part of efforts to reduce bureaucracy. NHS England’s covid support fund for practices should be rolled over until March 2021 and expanded to ensure that all additional costs such as additional telephony and cleaning are included, it added. Vautrey said, “The measures we’ve outlined are aimed at supporting practices and their staff to deliver high quality care while managing the increased pressures of doing so during a pandemic, and it is vital that the government and NHS England listen and implement these urgently, to ensure that primary care can continue to operate safely through what looks to be an incredibly difficult winter.” Read full story Source: BMJ, 1 October 2020
  18. News Article
    The surgeon at the centre of a body parts scandal operated on patients who were dangerously sedated so that their procedures could be carried out simultaneously, according to a leaked investigation seen by The Independent. Renowned hip surgeon Derek McMinn and two anaesthetists at Edgbaston Hospital, Birmingham, were accused of putting “income before patient safety” in the internal investigation for BMI Healthcare, which runs the hospital. It comes after a separate review found that McMinn had hoarded more than 5,000 bone samples from his patients without a licence or proper permission to do so over a period of 25 years, breaching legal and ethical guidelines. Police are investigating a possible breach of the Human Tissue Act. According to the report on sedation by an expert from another hospital, the two anaesthetists, Imran Ahmed and Gauhar Sharih, sedated patients for so long that their blood pressure fell to dangerous levels in order to allow McMinn to carry out near-simultaneous surgery. It found this meant long delays in the operations starting, with one sedated patient being subjected to prolonged anaesthesia for longer than one hour and 40 minutes – recommended best practice is 30 minutes. Another patient was apparently "abandoned" for an hour and 26 minutes after their surgery was only partially completed while McMinn began operating on another patient. The report’s author, expert anaesthetist Dr Dhushyanthan Kumar of Coventry’s University Hospital, said this was unsafe practice by all three doctors and urged BMI Healthcare to carry out a review of patients to see if any had suffered lasting brain damage. Both anaesthetists work for the NHS – Ahmed at Dudley Group of Hospitals, Sharih at University Hospitals Birmingham – without restrictions on their ability to practise. Read full story Source: The Independent, 30 September 2020
  19. News Article
    Doctors and carers should look out for signs of confusion or strange behaviour in frail older people because it could be an early warning sign of COVID-19, research suggests. Even if they have no cough or fever, delirium is more common in vulnerable over-65s than other, fitter people of the same age. But it's not yet clear why this extreme confusion or delirium happens. In this King's College London study, data from more than 800 people over the age of 65 was analysed. They included 322 patients in hospital with COVID-19, and 535 people using the Covid Symptom Study app to record their symptoms or log health reports on behalf of friends and family. All had received a positive test result. The researchers found that older adults admitted to hospital who were classified as frail were more likely to have had delirium as one of their symptoms, compared with people of the same age who weren't frail. For one in five patients in hospital with Covid, delirium was their only symptom. The study calls for more awareness of it in hospitals and care homes. Read full story Source: BBC News, 30 September 2020
  20. News Article
    Almost nine in ten maternity services experienced a decline in emergency pregnancy appointments during the pandemic due to women avoiding healthcare providers amid coronavirus chaos, a study has found. The Royal College of Obstetricians and Gynaecologists, who carried out the research, said women refrained from attending appointments due to anxiety around going into a hospital and fears of overwhelming the NHS, as well as not being clear if the appointments were essential. Researchers found 70% of maternity services reported a reduction in antenatal appointments, while 60% of units stopped the option of giving birth at home or in a midwife-led unit. Over half of services said postnatal appointments after childbirth had been reduced. The findings come as maternity services warn staff must not be sent to work in other parts of the hospital in the wake of a second wave of coronavirus. Royal College of Obstetricians & Gynaecologists and the Royal College of Midwives, who together represent the overwhelming bulk of maternity staff, say there must not be a repeat of the acute and widespread maternity staff shortages which played out during the health emergency’s peak. Read full story Source: The Independent, 30 September 2020
  21. News Article
    The stress and anxiety caused to patients by "poor communication" from NHS bodies in England during the covid pandemic has been criticised by MPs. While recognising the huge burden placed on the NHS, their report said cancelled treatments and surgery had left some "in limbo" and others "too scared" to seek medical help. The report also questioned why weekly testing of NHS staff had not yet begun. And it called for their mental and physical wellbeing to be supported. Jeremy Hunt, who chairs the Health and Social Care Committee, which compiled the report, praised the "heroic contribution" made by front-line NHS staff during the pandemic, which had saved many lives. But he said the pandemic had "massively impacted normal NHS services" and this situation could have been improved with clearer communication to patients and better infection control measures in hospitals. The report, based on evidence from doctors, nurses, patient groups and NHS leaders, said the case for routine testing for all NHS staff in all parts of the country was "compelling" and it should be introduced as soon as possible before winter to help reduce the spread of the virus. The government and NHS England told the committee they wanted to bring in routine testing of staff but any plans depended on the capacity available. Read full story Source: BBC News, 1 October 2020
  22. Event
    until
    As we face the challenge of responding to the COVID-19 pandemic we need to apply what we have learnt so far, and what we continue to learn. It is a fast-moving evolving situation and as with any new strain of virus, the guidance for healthcare workers and health and social care services is being developed and updated frequently. In is a fast-moving evolving situation, we need ensure that our approaches and support for staff enables patient safety. The aims of this webinar from GovConnect is to: To explore how staff roles, training and decision-making impacts on patient safety. To explore the opportunities and barriers that staff face in delivering safe care. To engage in debate with a specialist expert leaders with experience in care delivery, academic research, clinical education, medical device manufacture, human factors and ergonomics, innovation and technology. To engage with participants to gain insights from front line clinicians, educators and patient safety experts. To identify action for change and improvement. Presenters: Helen Hughes, Chief Executive Officer, Patient Safety Learning Professor Matthew Cripps, Director of Covid-19 Behaviour Change Unit, NHS England & Improvement Cheryl Crocker, Patient Safety Director, AHSN Network Clare Wade, Head of Patient Safety, Royal College of Physicians Paul Hinchley, Clinical Services Manager, Philips Healthcare Register
  23. Content Article
    The Health and Social Care Committee is calling for urgent action to assess and tackle a backlog of appointments and an unknown patient demand for all health services, specifically across cancer treatments, mental health services, dentistry services, GP services and elective surgery. MPs say a compelling case has been made for the nationwide routine testing of all NHS staff and they are yet to understand why it cannot be introduced.
  24. Content Article
    Paula McGowan is a Multi Award-winning Activist who following the preventable death of her teenage son Oliver, has dedicated her life to campaigning for equality of Health and Social Care for Learning Disabled people and Autistic people. She is an Ambassador for several charities and organisations. Paula launched a parliamentary petition asking for all doctors and nurses to receive mandatory training in Learning disability and Autism awareness. She ferociously argued that autism must be included. On 22 October 2018, her petition was debated and gained cross party support. As a direct consequence Government announced that all NHS and Social Care Staff would receive The Oliver McGowan Mandatory Training in Learning Disability and Autism. On the Oliver's Campaign website you can find support, resources and blogs.
  25. Content Article
    Although airway safety is known to be one of the key components in safe care, thousands of patients lose their lives each year to poor airway management and unplanned extubations. In this Patient Safety Movement webinar, the team discusses starting an unplanned extubation project without buy-in from others, multi-institutional collaboration, pushback from leaders, colleagues, or other organisations, the future of interventions, clinicians who have experience with unplanned extubations as key advocates, and cross-checking pediatric and adult safety efforts. The panel ends with Drew Hughes’ story and the team emphasises taking a moment to ground yourself in your practice and the importance of speaking up when you think the patient is at risk.
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