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Patient Safety Learning

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  1. Content Article
    The Private Healthcare Information Network (PHIN) has published new information about serious patient safety incidents for private acute care. The data, covering the period 1 January 2019 to the 31 December 2019, show that 21 Never Events involving non-NHS (insured or self-pay) patients were reported.
  2. News Article
    The use of inexpensive steroids in treating patients hospitalised with COVID-19 has been found to reduce the risk of death by 20%, according to a new international study. The research encompassed seven clinical trials, which focused on three different types of anti-inflammatory corticosteroids, and was co-ordinated by the World Health Organization (WHO). Following the publication of the findings, the WHO issued new guidelines in which it recommended the use of corticosteroids as standard treatment for patients with “severe and critical” COVID-19. The study, analysed by the National Institute for Health Research (NIHR) at the University of Bristol, looked at patient mortality over a 28-day period after treatment. It found that corticosteroid treatment led to an estimated 20% reduction in the risk of death. Researchers said it was equivalent to about 68% of critically ill patients surviving after treatment with the steroids, compared to approximately 60% surviving without them. Jonathan Sterne, professor of medical statistics and epidemiology at the University of Bristol, said: “Steroids are a cheap and readily available medication, and our analysis has confirmed that they are effective in reducing deaths amongst the people most severely affected by COVID-19." Read full story Source: The Independent, 2 September 2020
  3. News Article
    There were 21 “wholly preventable” patient safety incidents of the most serious category at private hospitals last year, new data has shown, as NHS bosses prepare to invest up to £10bn in the sector. This is the first time that a comprehensive dataset of 'never events’ within private hospitals has been published in the UK, and comes ahead of plans to outsource both inpatient and outpatient services, routine surgery operations and cancer treatment to private providers. The audit conducted by the Private Healthcare Information Network (PHIN), established in 2014 to bring greater transparency to the private health sector, showed that 287 out of 595 private hospitals and NHS private patient units (PPUs) provided information on Never Events between 1 January and 31 December 2019. This group accounts for an estimated 86 per cent of privately-funded admitted patient care, PHIN said. It attributed the “gaps in the data” to NHS PPUs, rather than independent hospitals. The fact that more than 300 hospitals or PPUs were unable or unwilling to hand over this data highlights the private sector’s continuing lack of transparency, said the Centre for Health and the Public Interest, a social care and health think tank. Read full story Source: The Independent, 2 September 2020 Private Healthcare Information Network press release
  4. News Article
    Testing people twice for the coronavirus, with a nasal swab followed by an antibody finger prick test, would catch most of those people who fail to get the right COVID-19 diagnosis, researchers believe. Nose and throat swabs miss around 30% to 50% of infections, say the University of Cambridge team, as the virus can disappear from the upper respiratory tract into the lungs. But they say adding an antibody test can plug that gap. Antibodies show up from about six days after infection. A team at Addenbrooke’s hospital in Cambridge has piloted the use of combined tests for patients arriving at the hospital. Many arrive with flu-like symptoms and need an accurate diagnosis to ensure they are put on the right wards, so that there is no risk of COVID-19 patients infecting others. Read full story Source: The Guardian, 2 September 2020
  5. Content Article
    The COVID-19 pandemic has placed an enormous strain on health care workers, and its potential impact has implications for the physical and emotional well-being of the workforce. As hospital systems run well over capacity, facing possible shortages of critical care medical resources and personal protective equipment as well as clinician deaths, the psychological stressors necessitate a strong well-being support model for staff. In this commentary, Ripp et al. describe how an MSHS Employee, Faculty, and Trainee Crisis Support Task Force—created in early March 2020 and composed of behavioural health, human resources, and well-being leaders from across the health system—used a rapid needs assessment model to capture the concerns of the workforce related to the COVID-19 pandemic. The task force identified 3 priority areas central to promoting and maintaining the well-being of the entire MSHS workforce during the pandemic: meeting basic daily needs; enhancing communications for delivery of current, reliable, and reassuring messages; and developing robust psychosocial and mental health support options. Using a work group strategy, the task force operationalised the rollout of support initiatives for each priority area. Attending to the emotional well-being of health care workers has emerged as a central element in the MSHS COVID-19 response, which continues to be committed to the physical and emotional needs of a workforce that courageously faces this crisis.
  6. News Article
    A dementia charity is seeking a judicial review of the government guidance on care home visits. John's Campaign says many care homes in England are still refusing regular face-to-face visits, often essential for people with severe dementia. Dr Angela McIntyre, a retired doctor backing the campaign, has not seen her 92-year-old mother since March. A Department of Health spokesman said: "We know limiting visits in care homes has been difficult for many families." He added: "Our first priority is to prevent infections in care homes, and this means that visiting policy should still be restricted with alternatives sought wherever possible. "Visiting policies should be tailored by the individual care home and take into account local risks in their area." But John's Campaign believes the guidance does not take into account how important visits from family members are for dementia patients and believes it could be in breach of the law. Read full story Source: BBC Health, 3 September 2020
  7. Event
    A free virtual QI conference with support from the Academic Health Science Network. There are 20 prizes available, 15 workshops with certificates (and CPD), 5 keynote speeches from international leaders discussing QI themes. Further information and registration The abstract support team will be available at abstracts@qisw.uk and they will help guide submitters through the abstract submission process – a great opportunity for junior trainees, nurses and allied healthcare professionals who may not have had the opportunity. Abstract deadline 7 September 2020.
  8. News Article
    Pregnant women in hospital with COVID-19 are less likely to show symptoms than non-pregnant women of similar age but may have an increased risk of admission to intensive care, a study published in The BMJ has found. Researchers from the UK, the US, Spain, China, Switzerland, and the Netherlands found that pregnant women with COVID-19 were also more likely to have a preterm birth and that their newborns were more likely to be admitted to a neonatal unit. Other factors that increased the risk of severe COVID-19 in these women included being older, being overweight, and having pre-existing medical conditions such as hypertension or diabetes. The authors concluded that healthcare professionals needed to be aware that pregnant women with COVID-19 might need access to intensive care and specialist baby care facilities and suggested that mothers with pre-existing comorbidities should be considered to be a high risk group for COVID-19, along with those who were obese or older. Read full story Source: BMJ, 2 September 2020
  9. News Article
    Nurses and essential healthcare staff could be left redundant in the middle of the pandemic as local authorities look to make changes to healthcare contracts that would leave patients facing major disruption, NHS bosses have warned. NHS Providers, which represents all NHS trusts, and NHS Confederation, which represents health and care organisations, said that the decision to put contracts for public health services out to tender as workers battle coronavirus in the community is “completely inappropriate” and a “damaging distraction”, creating uncertainty for those who have spent the past six months on the COVID-19 frontline. Shadow health minister Jonathan Ashworth told The Independent: “This process is disruptive and wasteful at the best of times, but to be doing this mid-pandemic is risky, unnecessary and undermines the ability of frontline health workers to focus not only on preparations for a potential second wave, but a whole host of other health issues, such as Covid rehabilitation, community mental health services and children’s health, all of which are now urgent priorities.” Read full story Source: The Independent, 1 September 2020
  10. News Article
    Pilots for a new urgent care model requiring walk-in patients to book slots in emergency departments are expected to be rolled out in at least one site in every health system in the coming weeks, HSJ has learned. The move comes amid concerns from trust managers who warned some 111 providers’ systems were too “risk averse” and were sending too many patients who could have been treated in other care settings to hospitals. Local managers believe NHS 111 not directing enough people to alternative services was a cause of a major incident at Gloucestershire Hospitals Foundation Trust’s emergency services earlier this month, HSJ understands. And trust leaders in other parts of the country are understood to have similar concerns. Trials of 111 First have already been publicly confirmed at Portsmouth Hospitals Trust, Royal Cornwall Trust, Newcastle Hospitals FT and Blackpool Hospitals FT. HSJ also understands five London sites, one for each integrated care system in the capital, are also running trials. These “early adopter” trusts have been given autonomy to trial different models for “111 First”. Most EDs at these sites still treat “walk-in patients” as normal. But in Portsmouth, patients with minor injuries who turn up at ED without calling ahead have, on three different days, been instead told to call 111 following assessments. NHS England said further trials will take place in the Midlands and East of England, but the specific trusts undertaking these trials have not been decided yet. Read full story (paywalled) Source: HSJ, 2 September 2020
  11. Content Article
    This prospective study aimed to determine the surgical site infection (SSI) rate and associated risk factors was carried in a general surgical ward at Liaquat University Hospital Jamshoro. A total of 460 patients requiring elective general surgery from July 2005 to June 2006 were included in this study. All four surgical wound categories were included. Primary closure was employed in all cases. Patients were followed up to 30th day postoperatively. All cases were evaluated for postoperative fever, redness, swelling of wound margins and collection of pus. Cultures were taken from all the cases with any of the above finding. The overall rate of surgical site infection was 13·0%. The rate of wound infection was 5·3% in clean operations, 12·4% in clean‐contaminated, 36·3% in contaminated and 40% in dirt‐infected cases. Age, use of surgical drain, duration of operation and wound class were significant risk factors for increased surgical site infection.. Postoperative hospital stay was double in cases who had surgical site infection. Sex, haemoglobin level and diabetes were not statistically significant risk factors. In conclusion, surgical site infection causes considerable morbidity and economic burden. The routine reporting of SSI rates stratified by potential risk factors associated with increased risk of infection is highly recommended.
  12. Content Article
    Responding to abnormalities in patients’ vital signs is a fundamental aspect of nursing. However, failure to respond to patient deterioration is common and often leads to adverse patient outcomes. This study from Smith et al., in the journal Resuscitation, aimed to determine the association between registered nurse (RN) and nursing assistant (NA) staffing levels and the failure to respond promptly to patients’ abnormal physiology. The authors found that RN, but not NA, staffing levels influence the rates of failure to respond for patients with the most abnormal vital signs (NEWS values ≥ 7). These findings offer a possible explanation for the increasingly reported association between low RN staffing and an increased risk of patient death during a hospital admission.
  13. Content Article
    In 2019 The King's Fund discussed the following eight key problems facing social care and called for reforms to address them: means testing: social care is not free at point of use like the NHS catastrophic costs: some people end up paying large amounts and even selling their homes to pay for care unmet need: many people go without the care and support they need quality of care: a wide spectrum of concerns, from 15-minute care visits to neglect and lack of choice and control workforce pay and conditions: staff are underpaid, leading to high vacancy rates and turnover market fragility: care providers go out of business or hand back contracts disjointed care: health and care is not integrated around the individual and causes issues such as delayed transfers of care from hospital the ‘postcode lottery’: there is unwarranted variation between places in access to care and its quality. The pandemic has shone an uncompromising light on the social care sector. In this article, Simon Bottery explores how COVID-19 has exacerbated these pre-existing challenges.
  14. Content Article
    Neil Spenceley is a paediatric intensivist and is the National Lead for Paediatric Patient Safety. This talk is packed with nuggets that will change the way you view the world in which you practice. Neil explains Safety 1 and Safety 2 thinking. The talk is wide-ranging and covers poor behaviours in healthcare both at a personal level and at an institutional level. This talk was recorded live at Don't Forget the Bubbles 2019 in London, England.
  15. Content Article
    Have you ever been faced with an upcoming shift at work and felt an impending sense of doom? It comes as no surprise that doctors — real, human people — have a certain degree of anticipation, even anxiety, when it comes to taking shifts. Katie Townes, a physician and founder of Physician Lounge Online, shares her path to on-call acceptance.
  16. Content Article
    On Thursday 30 July 2020, NHS England and NHS Improvement published the NHS People Plan for 2020/21. Building on the Interim NHS People Plan released in 2019, it describes itself as focusing on “how we must all continue to look after each other and foster a culture of inclusion and belonging, as well as action to grow our workforce, train our people, and work together differently to deliver patient care”. In this blog, Patient Safety Learning looks at the People Plan with specific reference to its approach to tackling the blame culture in the NHS, which is a significant factor in the safety of patients and staff. It highlights where we think the People Plan has not addressed these well-known concerns and what more needs to be done urgently.
  17. Content Article
    Structuring and presenting healthcare information that aligns with a patient’s level of understanding can help patients achieve optimal outcomes. Verbal communication strategies such as “teach back” and “Ask Me 3®” programmes and written strategies address opportunities identified in the event reports and may help improve patient understanding and engagement in their care. The Patient Safety Authority have collated guidance, resources and education tools on health literacy.
  18. Content Article
    In the past, healthcare workers considered bed rails a useful device to prevent patient falls from bed. While bed rails have their benefits, their use or misuse may also place patients at significant risk, resulting in death or serious injury. Entrapment is an occurrence involving a patient who is caught, trapped, or entangled in the hospital bed system, which includes the spaces in or around the bed rail, hospital bed mattress, or hospital bed frame. Entrapped body parts associated with risk for severe injury include the head, neck, and chest. Awareness of this risk must be heightened across the healthcare continuum. The Patient Safety Authority has collated guidelines, resources and educational tools on bed safety.
  19. Content Article
    The NHS Leadership Academy recognises the crucial importance of effective, engaged, accountable board leadership and has commissioned this refreshed edition of ‘The Healthy NHS Board 2013 - Principles for Good Governance’. This guidance supports the NHS Leadership Academy’s mission to develop outstanding leadership in health in order to improve people’s health and their experience of the NHS.
  20. Content Article
    The COVID-19 pandemic will impact the health of many people in England and unfortunately many people will lose their lives. This paper from the Department of Health and Social Care, Office for National Statistics, Government Actuary’s Department and Home Office, provides a summary of research and analysis, discussing and estimating the health impacts (both excess deaths and morbidity) from the pandemic.
  21. Content Article
    During the COVID-19 pandemic, you might experience immense pressure and stressors. The World Health Organization has provided an infographic highlighting what stress is, how it might affect you and practical tips on what you can do.
  22. Content Article
    Is the Government oblivious to the avoidable harm caused to non-COVID patients as a result of disruption to health services during the pandemic? Or worse, is it trying to bury bad news? On 18 June 2020, Peter Walsh, Chief Executive, Action against Medical Accidents (AvMA), together with other organisations and experts, wrote to the Prime Minister and the First Ministers of the UK nations about avoidable harm being caused to non-COVID patients as a result of prolonged disruption to health services since the start of the COVID-19 pandemic. However, at the time of writing this blog, there has been no response to that letter Peter asks whether the failure to acknowledge the problem and ensure that it is urgently addressed, or even to show empathy with those affected, is at best irresponsible and deeply disrespectful to all those affected or at risk, or, at worst, whether it could be a conscious decision to bury bad news and avoid responsibility.
  23. Content Article
    A memoir of the chaos, intensity and occasional beauty of life as a paramedic. Jake Jones has worked in the UK ambulance service for 10 years: every day, he sees a dozen of the scenes we hope to see only once in a lifetime. Can You Hear Me? - the first thing he says when he arrives on the scene - is a memoir of the chaos, intensity and occasional beauty of life on the front-lines of medicine in the UK. As well as a look into dozens of extraordinary scenes - the hoarder who won't move his collection to let his ailing father leave the house, the blood-soaked man who tries to escape from the ambulance, the life saved by a lucky crew who had been called to see someone else entirely - Can You Hear Me? is an honest examination of the strains and challenges of one of the most demanding and important jobs anyone can do.
  24. News Article
    We have been coughed on and shouted at by people refusing to wear face masks. We need more protection, says NHS paramedic Jake Jones. The outpouring of appreciation for NHS staff during the COVID-19 crisis has been extraordinary. Yet reports of a recent rise in attacks on emergency workers, including ambulance crews, in England and Wales suggests the Thursday evening applause was hiding a less positive reality. Abuse of emergency workers is a growing issue: a 2018 survey found that 72% of ambulance staff have been attacked on duty, and figures have repeatedly pointed to an upward trend. As an NHS paramedic for 10 years, this aligns with Jake's own experience. The consultation on increasing sentences for assaults on emergency workers seeks to discourage attacks on them. Jake's hope is that it will also challenge what has become an ingrained view – that being abused and assaulted somehow goes with the territory. Read full story Source: The Guardian, 1 September 2020 Read Jake's book 'Can you hear me? An NHS paramedics encounters with life and death'
  25. Content Article
    Patient Safety Learning’s formal response to the Healthcare Safety Investigation Branch’s (HSIB) report looking into a safety risk concerning guidelines around the use of personal protective equipment to reduce the risk of COVID-19 transmission when delivering care in people’s homes.
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