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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    A short article from NHS Education for Scotland about Significant event analysis (SEA). Enhanced SEA is a well-established safety improvement tool in general practice. However, there is good evidence to suggest that many SEAs are poorly conducted by practice teams, leading to missed opportunities to make health care safer.
  2. News Article
    Almost half of NHS Trusts in England have reported risks classified as “significant” or “extreme”, with issues facing funding, buildings and failing equipment, according to an analysis by Labour. Highlighting warnings of staff shortages and patient safety, the party demanded urgent action from the government to prepare the health service for the winter months as cases of COVID-19 accelerate across the country. Labour said its study of 114 NHS Trusts’ risks registers showed that over three quarters of trusts logged a workforce risk. The analysis also revealed that 66% reported a financial risk, 82% highlighted risks directly related to COVID-19 and 84% recorded a risk to patient safety. Almost half of Trusts (54), the party said, had outlined risks described as “significant” or “extreme”. One hospital trust reported it was “not financially stable” beyond the current financial year while another recorded a potential risk to patient safety due to “structural deficiencies” in roof structure. NHS hospitals are expected to consider risks to their operations and processes and when risks are identified, it is likely they will have been considered at board level and mitigations put in place. Describing the registers – compiled between March and August - as “worrying” in a normal winter, Jonathan Ashworth, the shadow health secretary, said: “In the coming winter, with the incompetent handling of the test and trace system leaving the NHS wide open and poorly supported, they take on a whole new meaning." "We urgently need a commitment from ministers to fix the problems with test and trace and a timetable by which these issues will finally be sorted. On top of this it is vital that ministers confirm that the NHS will get the additional support it needs to address these risks." Read full story Source: The Independent, 6 October 2020
  3. Event
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    This high profile conference will be attended by GPs, Social Prescribing Link Workers, Social Prescribing programmes, Community, Health and Social Care industry leaders, Primary Care Networks, Clinical Directors, Practice Managers and Line Managers from across sectors in the United Kingdom. Celebrate, network, discover the latest updates and learn best practices to power up community wellbeing through social prescribing. Further information and registration
  4. Content Article
    The aim of this study from Jardine et al. was to determine the rate of complicated birth at term in women classified at low risk according to the National Institute for Health and Care Excellence guideline for intrapartum care (no pre-existing medical conditions, important obstetric history, or complications during pregnancy) and to assess if the risk classification can be improved by considering parity and the number of risk factors. The authors found nulliparous women without risk factors have substantially higher rates of complicated birth than multiparous women without a previous caesarean section even if the latter have multiple risk factors. Grouping women first according to parity and previous mode of birth, and then within these groups according to presence of specific risk factors would provide greater and more informed choice to women, better targeting of interventions, and fewer transfers during labour than according to the presence of risk factors alone.
  5. News Article
    The Prime Minister has confirmed a £3.7bn funding package to facilitate the construction of 40 new hospitals around the England by 2030, with a further eight schemes invited to bid for future funding. Talked about over the coming months, the funding announcement comes as the first official confirmation to deliver on the Government’s manifesto commitment. New standards are set to be developed over the coming months to help standardise the design of new hospitals and make use of modular construction methods to speed up the build process. Originally launched last September with a £2.8bn investment which provided six new hospitals with the funding to go ahead, alongside seed funding for trusts to work up business cases, the health infrastructure plan (HIP) represents the largest hospital building programme in the UK for a generation. The trusts which received seed funding will now all be fully funded to deliver 25 new hospitals. An additional site – a new hospital in Shotley Bridge – has also been added to the programme. The new Shotley Bridge hospital represents a commitment from the Government to ensure much of the funding also goes to rebuilding across the North of England, as part of its levelling up agenda. As part of welcoming new schemes to bid for funding for the eight further new hospitals down the line, the Government also committed that a proportion of these would be new mental health hospitals. Prime Minister Boris Johnson said: “The dedication and tireless efforts of our nurses, doctors and all healthcare workers have kept the NHS open throughout this pandemic. But no matter what this virus throws at us, we are determined to build back better and deliver the biggest hospital building programme in a generation." Read full story Source: NHE, 5 October 2020 40hospitals.pdf
  6. Content Article
    The COVID-19 pandemic has resulted in an unprecedented level of public scrutiny of patient care, and developing highly reliable systems is no longer going to be optional for organisations in the future. Healthcare leaders are now challenged to implement new cultures focussed on sustaining safe, person-centred care for both patients and health workers.  HealthManagement.org features The Patient Safety Movement Foundation's Chief Clinical Officer, Dr Donna Prosser, to offer insight regarding the unprecedented level of public scrutiny of patient care and how we can adjust moving forward. 
  7. Content Article
    The quality and safety of patient care relies on good communication, teamwork and respect between staff. However, in many areas of the NHS hierarchical attitudes lead to a dictatorial approach in which senior nurses make decisions affecting their colleagues without any discussion or consideration of the impact and practicality of these decisions. This can lead to dysfunctional organisational cultures in which staff either tolerate and emulate disrespect or leave the profession. Ellen Wightman, a staff nurse at University Hospitals Bristol NHS Foundation Trust, reflects on the importance of nurses being supported in developing leadership skills – and having the motivation to create collaborative and positive cultures.
  8. Event
    At THIS Space, we welcome researchers, patients, carers, NHS staff and anyone with an interest in the evidence base for improving the quality and safety of healthcare. THIS Space 2020 event will take place entirely online and create an opportunity for people interested in the study of healthcare improvement to gather, connect, and share ideas remotely. THIS Space aims to: provide a focus for knowledge sharing in healthcare improvement stimulate innovation and fresh thinking help researchers to develop the habits, knowledge, skills, and experiences to support their professional growth connect colleagues from across different disciplines who share a common goal be a means of accelerating the development of the field of the study of healthcare. Plenary sessions: Professor Bob Wachter will explore an international perspective on the legacy of COVID-19 in healthcare improvement and research. Professor Ramani Moonesinghe will discuss the impacts of rapid innovations in healthcare. Dr Victoria Brazil will examine the role of simulation in healthcare improvement studies. Registration
  9. Content Article
    In this International Society for Quality in Healthcare (ISQua) webinar, Eugene Litvak discussed streamlining patient flow to improve access to care and its quality, and reduce cost. Other benefits include lower staff turnover rates, improved organisation culture and improved patient outcomes. Eugene gives a number of examples of hospitals where this 're-engineering' of pathways has resulted in increased performance and reduced risk.
  10. Content Article
    A lower recruitment and high turnover rate of registered nurses have resulted in a global shortage of nurses. In the UK, prior to the COVID-19 epidemic, nurses’ intention to leave rates were between 30 and 50% suggesting a high level of job dissatisfaction. In this study, published in BMC Nursing, Senek et al. analysed data from a cross-sectional mixed-methods survey developed by the Royal College of Nursing and administered to the nursing workforce across all four UK nations, to explore the levels of dissatisfaction and demoralisation – one of the predictors of nurses’ intention to leave.
  11. Content Article
    The NHS Staff Survey is one of the largest workforce surveys in the world and has been conducted every year since 2003. It asks NHS staff in England about their experiences of working for their respective NHS organisations. Follow the link below for further information and to complete the survey.
  12. Content Article
    Human factors is a scientific discipline which is used to understand the interacting elements and design of a complex system, aimed at improving system performance and optimising human well-being. This book brings together a range of specialist authors to explore some of the key concepts of human factors related to the field of paramedic practice. The system elements of paramedic practice can include the patient, the paramedic and their colleagues, the environment, the equipment, the tasks, and the processes and procedures of the organisation. The relationships between these components are explored in detail through chapters which cover ‘human error’, systems thinking, human-centred design, interaction with the patient, non-technical skills of individuals and teams, well-being of the paramedic, safety culture and learning from events. This helpful and informative guide provides frontline paramedics and ambulance clinicians with practical advice and knowledge of human factors that will be helpful in supporting safe and effective practice for all involved. It will also be of interest to pre-hospital care professionals who are involved in education, learning from events, procurement and influencing safety culture. Above all, it shows how an understanding and application of human factors principles can enhance system performance and well-being, and ultimately lead to safer patient care.
  13. News Article
    A further £8.7million is to be dished out to seven NHS hospital trusts to introduce digital records and e-prescribing. The money is part of a £78million investment which was announced in February 2018 and aims to accelerate the roll out of electronic prescribing systems across the NHS. The latest funding is part of the third wave of the investment, which will be handed out over three years. In 2018/ 19, £16.2 million was awarded, £29.4 million was given in 2019/20 and another £12 million will be invested later this year. The seven trusts which will benefit from this latest round of finding are: Portsmouth Hospitals NHS Trust (£1.7m) Solent NHS Trust (£988,000) Sussex Community NHS Foundation Trust (£637,000) United Lincolnshire Hospitals NHS Trust (£1.26m) North Cumbria Integrated Care NHS Trust (£2m) East Lancashire Hospitals NHS Trust (£1.6m) Birmingham Community NHS Trust (£531,000) National director of patient safety, Dr Aidan Fowler, said: “Patient safety is of paramount importance and is something we are continuously looking at ways to improve, whether through new technology, such as the introduction of electronic prescribing, or by building a safety culture where all NHS staff feel supported and safe to speak up.” Read full story Source: Digital Health, 1 October 2020
  14. News Article
    NHS Payouts linked to medication blunders have doubled in six years, fuelling record spending, official figures show. The NHS figures show that in 2019/20, the health service spent £24.3 million on negligence claims relating to medication errors - up from £12.8 million in 2013/14. The statistics show that in the past 15 years, almost £220 million has been spent on claims relating to the blunders. Previous research has suggested that medication errors may be killing up to 22,000 patients in England every year. Errors occur when patients are given the wrong drugs, doses which are too high or low, or medicines which cause dangerous reactions. In some cases, patients have been given medication which was intended for another person entirely, sometimes with fatal consequences. Other studies suggest that 1 in 12 prescriptions dispensed by the NHS involve a mistake in medication, dose or length of course. In some cases, patients have died after being given a dose of morphine ten times that which should have been administered, with other fatalities involving fatal reactions. Confusion often occurs when drugs are not labelled clearly, or when packaging of different medications looks similar. Jeremy Hunt, now chairman of the Commons Health and Social Care Committee, said the NHS needed to make far more progress preventing harms, instead of seeing an ever increasing negligence bill. He said: “It is nothing short of immoral that we often spend more cleaning up the mess of numerous tragedies in the courts, than we actually do on the doctors and nurses who could prevent them." Read full story (paywalled) Source: The Telegraph, 3 October 2020
  15. News Article
    Melissa Vanier, a 52-year-old postal worker from Vancouver, had just returned from holiday in Cuba when she fell seriously ill with COVID-19. “For the entire month of March I felt like I had broken glass in my throat,” she says, describing a range of symptoms that included fever, migraines, extreme fatigue, memory loss and brain fog. “I had to sleep on my stomach because otherwise it felt like someone was strangling me.” By the third week of March, Vanier had tested negative for Sars-CoV-2 – the virus that causes Covid-19. But although the virus had left her body, this would prove to be just the beginning of her problems. In May, she noticed from her Fitbit that her heart rate appeared to be highly abnormal. When cardiologists conducted a nuclear stress test – a diagnostic tool that measures the blood flow to the heart – it showed she had ischaemic heart disease, meaning that the heart was not getting sufficient blood and oxygen. Similar stories illustrate a wider trend – that the coronavirus can leave patients with lasting heart damage long after the initial symptoms have dissipated. Cardiologists are still trying to find out exactly why some people are left with enduring heart problems despite having had an apparently mild bout of COVID-19. The underlying mechanisms are thought to be slow and subtle changes that are quite different to those that put strain on the heart during the acute illness, especially in patients who have been hospitalised with the disease. Some cardiologists have suggested that treatments such as cholesterol-lowering drugs, aspirin or beta blockers may help patients with lingering cardiovascular effects many weeks or months after the initial infection, but the evidence remains limited. “It is too early to share data on this,” says Mitrani. “But these therapies have proven efficacy in other inflammatory heart muscle diseases. They have anti-inflammatory effects and we believe may help counter some of the lingering pro-inflammatory effects from Covid-19.” But for patients such as Vanier, there remains a long and uncertain road to see whether her heart does fully recover from the impact of the virus. “Psychologically this has been brutal,” she says. “I haven’t been back to work since I went on holiday in February. The heart hasn’t improved, and I now have to wait for more tests to see if they can find out more.” Read full story Source: The Guardian, 4 October 2020
  16. News Article
    Omnicell UK & Ireland, a leading provider of automated healthcare and medication adherence solutions, hosted a health summit on the eve of World Patient Safety Day, to discuss the impact of medication errors on patients and the NHS. The session focussed on the role technology can play in preventing such issues. The summit, this year held via webinar, comes off the backdrop of the Department of Health and Social Care disclosing that in England 237 million mistakes occur every year at some point in the medication process. These errors cause serious issues for patient safety, but also place a significant cost burden on an already stretched NHS. The 2019 Patient Safety Strategy published by NHS England and NHS Improvement also found the NHS failed to save 11,000 lives a year due to safety concerns with the cost of extra treatment needed following incidents being over £1bn. A number of high-profile panel members answered a series of questions from the audience on solutions and best practice to improve patient safety with the aim of debating and sharing ideas on how to meet challenges and the impact of COVID-19. One of the panelists, Patient Safety Learning's Chief Digital Office Clive Flashman, agreed with the other panel members that the NHS had become more collaborative and familiar with technology since Covid: “We’ve seen a definite increase in telehealth and telemeds. Covid has forced cultural blockers that were there before to be removed out of necessity. There has been a growth in robotic pharmacy automation to free up staff time from high volume administration tasks to do more complex work that adds value for patients.” But with the second-wave of COVID-19 still a very real threat he advised: “We don’t want to wait until the next wave to learn a lesson – we need to learn lessons now. Quality Improvement Leads should be focussed on what went right and what went wrong over that period between March and May. They need to be looking at what we can learn from that now and what we can do differently next time. If we don’t do that, we won’t succeed in the second wave where we might fail.” Ed Platt, Automation Director, Omnicell UK & Ireland, added: “Challenges within the NHS throughout Covid has forced them to embrace technology and drive innovation." "It’s important that when things go back to normal, we don’t go back to the same status quo. We need to invest in the right infrastructure in hospitals so unnecessary demands and stress are not put on pharmacy, supply managers and nurses so they are free to focus on patient care not administration tasks." Read full story Source: NHE, 17 September 2020 You can watch the webinar on demand here
  17. Content Article
    Surgical instruments are essential for the delivery of modern healthcare. Their use is so widespread that they are easily taken for granted. The supplier base for instruments is diverse, including small, family owned businesses, and large multinational corporations. What they have in common are complex manufacturing processes, global supply chains, broad product ranges to suit varying clinical needs and product development with the capacity to innovate as required.
  18. News Article
    A 33-year-old woman says she's been suffering awful coronavirus symptoms for six months and says it's "ruined her life". Stephanie, from London, says her symptoms began in mid-March when she started experiencing loss of taste and smell, body aches, headaches, a fever, shivering, hot and cold sweats, and sickness. But six months later she still has had no sense of taste and smell, she suffers brain fog and chronic fatigue and says just walking across her flat leaves her chest feeling tight. The photographer, who lives alone, says she sleeps for 10-12 hours but is still always tired. "I'm only 33," she said. Stephanie wants to raise awareness of 'long Covid' and says more research needs to be done on how to treat the long-term effects of the disease. She said she's scared she'll 'never be the same again'. Stephanie says she has a hospital appointment on Friday to have tests on her lungs and heart as doctors are concerned she has lung damage. She added: "I think some people don't believe in long Covid, so I want to raise awareness of what people are going through. We need more research of how to treat people with long Covid because there isn't much available, it's so awful." Read full story Source: Mirror, 1 October 2020
  19. Content Article
    European drug regulations aim for a patient-centered approach, including involving patients in the pharmacovigilance (PV) systems. However many patient organisations have little experience on how they can participate in PV activities. The aim of this study published in Drug Safety, was to understand patient organisations’ perceptions of PV, the barriers they face when implementing PV activities, and their interaction with other stakeholders and suggest methods for the stimulation of patient organisations as promoters of PV.
  20. News Article
    From the moment coronavirus reached UK shores, public health advice stressed the importance of washing hands and deep-cleaning surfaces to reduce the risk of becoming infected. The advice was informed by mountains of research into the transmission of other respiratory viruses: it was the best scientists could do with such a new pathogen. But as the pandemic spread and data rolled in, some scientists began to question whether the focus on hand hygiene was as crucial as it seemed. The issue has resurfaced after Monica Gandhi, a professor of medicine at the University of California, San Francisco, told the US science magazine Nautilus that the easiest way to catch the virus was through droplets and aerosols sprayed from an infected person’s mouth or nose. “It’s not through surfaces,” she said. “We now know the root of the spread is not from touching surfaces and touching your eye. It’s from being close to someone spewing virus from their nose and mouth, without in most cases knowing they are doing so.” Gandhi’s is not a lone voice. Her comments follow a prominent paper in the Lancet from Emanuel Goldman, a professor of microbiology at Rutgers University in New Jersey. He was sceptical about the relevance of scientific studies that showed the virus could survive on surfaces for days at a time. “In my opinion,” he wrote, “the chance of transmission through inanimate surfaces is very small, and only in instances where an infected person coughs or sneezes on the surface, and someone else touches that surface soon after the cough or sneeze.” He defined soon as within one to two hours. Dr Julian Tang, an honorary associate professor of respiratory sciences at the University of Leicester, thinks hand washing should stay but agrees the risk from contaminated surfaces has been overplayed. He points to documents from the UK government’s Scientific Advisory Group for Emergencies (Sage) that estimate hand washing can reduce acute respiratory infections by only 16%. Meanwhile, he adds, the World Health Organization has warned about surfaces being a likely route of transmission while conceding there are no reports demonstrating infection this way. Tang believes that a preoccupation with contaminated surfaces distracted countries from taking airborne transmission seriously and played down the necessity of wearing masks. “What we’ve always said is that the virus transmits by all routes. There might be some transmission by hand and fomites and we’re not opposed to hand washing, but the emphasis is wrong,” he told the Guardian. Read full story Source: 5 October 2020
  21. Content Article
    "The night shift in A&E started off as normal: routine heart attacks, head injuries, road traffic accidents, an array of minor injuries. It was what happened next that has stayed with me for 25 years, long after I left my job as a doctor in the NHS." In this blog for the Guardian, a doctor reflects on the impact a traumatic night in A&E has had on them and their concerns for the mental health and wellbeing of all frontline staff during this global pandemic. Their hope is that immediate funding for a national framework of in-house support and counselling will stem the tsunami of mental ill health among frontline workers that is coming, and shed light on the ultimate medical taboo that is the mental health of our healthcare staff.
  22. Content Article
    As the pandemic approached England in early 2020, government policy decisions ensured most people stayed at home and NHS hospitals were largely protected. Yet some lives were not saved that should have been and England subsequently experienced the highest levels of excess mortality in Europe. Now as we head towards a winter living with COVID-19, a new hospital discharge policy suggests the English NHS has not learned from early mistakes and may be putting the lives of vulnerable people at risk.
  23. News Article
    The Care Quality Commission (CQC) is to target poorly performing NHS maternity units after a series of maternity scandals. It is drawing up plans to spot high-risk maternity units and will use data on their patient outcomes and culture to draw up a list of facilities for targeted inspection. The watchdog has voiced concerns over the wider safety of maternity units in the NHS after a number of high-profile maternity scandals in the past year. Almost two-fifths of maternity units, 38%, are rated as “requires improvement” by the CQC for their safety. The Independent has joined with charity Baby Lifeline to call on the government to reinstate a national maternity safety training fund for doctors and midwives. The fund was found to be successful but axed after just one year. On Tuesday, the CQC’s chief inspector of hospitals, Professor Ted Baker, told MPs on the Commons Health and Social Care Committee that he was concerned about the safety of mothers and babies in some maternity units which had persistent problems. “Those problems are of dysfunction, poor leadership, of poor culture, of parts of the services not working well together,” he said. “This is not just a few units; this is a significant cultural issue across maternity services.” Now the CQC has confirmed it is planning to draw up a list of poor-performing units or hospitals where it suspects there could be safety issues. The new inspection programme will specifically look at issues around outcomes and teamworking culture although the full methodology has yet to be decided. Read full story Source: The Independent, 4 October 2020
  24. Content Article
    'Long Covid' is a term is used to describe individuals who continue to suffer from COVID-19 symptoms outside of the two-week period in which they are believed to be infected. The World Health Organization (WHO) endorsed this two-week period as enough time for the virus and its symptoms to be able to come and go, yet studies are revealing cases in which symptoms are persisting well outside of this window. Survivors may have a chronic debilitating illness for many months.
  25. Content Article
    RIDDOR puts duties on employers, the self-employed and people in control of work premises (the Responsible Person) to report certain serious workplace accidents, occupational diseases and specified dangerous occurrences (near misses). There is no requirement under RIDDOR (The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013) to report incidents of disease or deaths of members of the public, patients, care home residents or service users from COVID-19. The reporting requirements relating to cases of, or deaths from, COVID-19 under RIDDOR apply only to occupational exposure, that is, as a result of a person’s work.
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