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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Complacency over the flu jab risks overwhelming the NHS, experts warn, as data reveals the scale of the challenge in expanding the vaccination programme. Last month, the government announced plans to double the number of people who receive the influenza jab. But BBC analysis has found the take-up rate among people in vulnerable groups eligible for a free jab has declined. Health secretary Matt Hancock said he did not want a flu outbreak "at the same time as dealing with coronavirus". The government wants to increase the number of people vaccinated from 15 million to 30 million amid fears coronavirus cases will rise again in the autumn. Local authorities in England saw an average 45% of people with serious health conditions under 65 take up the offer of a free vaccine last winter, data shows. That represents a drop from 50% in 2015. The UK government has an ambition to vaccinate 55% of people in vulnerable groups, which includes people with multiple sclerosis (MS), diabetes or chronic asthma. The World Health Organization (WHO) has previously said countries should vaccinate 75% of people in "vulnerable" categories. Read full story Source: BBC News, 27 August 2020
  2. News Article
    A clinical commissioning group (CCG) has ordered an independent review of its culture which it said was prompted by the “injustices experienced by black Asian and minority ethic colleagues” during the pandemic, HSJ has learned. The review at Surrey Heartlands CCG, due to report in the autumn, is being led by Duncan Lewis, emeritus professor of management at Plymouth University. He has led several major reviews into culture at NHS organisations, including one into bullying and harassment at South East Coast Ambulance Service Foundation Trust in 2017 and one into workplace culture at Whittington Health Trust in 2018. HSJ asked the CCG for the terms of reference of the review and the reasons why it felt it necessary to commission such an inquiry. It said the review’s scope would be determined by what staff felt was important regarding “our organisational culture, policy and practice – things we do well and things we need to improve”. It added in a statement: “We will listen to the findings of the review and we will make any changes that are necessary.” It is not yet clear if specific events within the organisation itself prompted the CCG to take the unusual step of commissioning the work. But the commissioner’s interim chief did say “feedback from staff” had been a driver. Read full story (paywalled) Source: HSJ, 26 August 2020
  3. News Article
    At least 6,500 health and care workers may have been infected with coronavirus through their work, including 100 who died, according to data from the Health and Safety Executive (HSE). The regulator told The Independent it was reviewing each case and could launch investigations under the Health and Safety at Work Act if hospitals or care homes are suspected of not taking adequate steps to protect staff from infection. This could result in a hospital or care home being prosecuted. The latest data from the HSE shows between 10 April and 10 August there were a total of 3, 382 healthcare workplace infections, including 50 fatal incidents. In residential care there were 3,168 infections reported to the watchdog with 48 fatal cases. The results of the review, first revealed earlier this month by The Independent, is being kept secret but where a medical examiner finds a worker may have died as a result of a workplace infection the death will have to be reported to the HSE for possible investigation. Coroners may also hold inquests into deaths. It will also make it easier for families to claim compensation from the government’s additional death in service payments of £60,000 which was announced by health secretary Matt Hancock in April. Read full story Source: The Independent, 25 August 2020
  4. News Article
    A nurse in the US sued Louisville, Ky.-based Kindred Healthcare this week, alleging the organisation fired him in retaliation for raising patient safety concerns. Sean Kinnie worked as an intensive care unit nurse at Kindred Hospital-San Antonio. Mr Kinnie claims he was suspended twice and then fired after leaders at the 59-bed transitional care hospital learned he anonymously reported patient safety concerns to The Joint Commission in November 2019 and January. Mr Kinnie said issues related to inadequate staffing and unsanitary care environments put patients in "grave danger," according to the lawsuit. He also said the hospital created a culture in which employees were afraid to stand up for patients for fear of retaliation from management. In January, Mr Kinnie told the hospital's chief clinical officer Sharon Danieliewicz that he was the staff member who reported the patient safety concerns to The Joint Commission. Mr. Kinnie claims he faced increased scrutiny after this disclosure and was ultimately fired Feb. 24 for violating facility policy. Read full story Source: Becker's Hospital Review, 24 August 2020
  5. News Article
    The Health Research Authority has launched a new strategy to ensure information about all health and social care research – including COVID-19 research - is made publicly available to benefit patients, researchers and policy makers. The COVID-19 pandemic has highlighted the importance of sharing details of research taking place - to understand the virus and find the tests, treatments and vaccines - so that results can inform best quality care and preventive measures. This also means researchers do not duplicate efforts and can build on each other’s work while the public can see what research is going on. Now the new Make it Public strategy aims to build on this good practice and make it easy for researchers to be transparent about their work. The strategy, delivered by the HRA in partnership with NHS Research Scotland (NRS), Health and Care Research Wales and Health and Social Care Northern Ireland, is about making transparency ‘the norm’ in research and making information more visible to the public. New measures set out in the strategy – will improve transparency and openness in health and social care studies, by: expecting researchers to plan how they will let research participants know about the findings of the study from the beginning introducing additional monitoring to check that researchers are reporting results and to collect information about study findings making information on individual research projects – and their transparency performance - available to the public introducing a system to consider past transparency performance when reviewing new studies for approval and in the future introducing sanctions.
  6. Content Article
    The aim of this systematic review in the Journal of Patient Safety was to determine the impact of automated patient monitoring systems (PMSs) on sepsis recognition and outcomes. Authors Gale and Hall found that automated sepsis PMSs have the potential to improve sepsis recognition and outcomes, but current evidence is mixed on their effectiveness. More high-quality studies are needed to understand the effects of PMSs on important sepsis-related process and outcome measures in different hospital units.
  7. Content Article
    Leaflets and a poster aimed at providing information on influenza (flu) and vaccination.
  8. Content Article
    In this report, the Care Quality Commission (CQC) explain the information they have gathered on the pressures that services and local systems have faced during COVID-19 and the efforts that have been made to tackle them. These insight reports are designed to help everyone involved in health and social care to work together to learn from the first stages of the COVID-19 pandemic by: sharing and reflecting on what has gone well understanding and learning from the experience of what hasn't helping health and care systems prepare better in the future.
  9. Content Article
    The Care Quality Commission (CQC) recognises the enormity of challenges faced by health and care providers in responding to coronavirus (COVID-19). At very short notice, services developed new procedures and ways of working. They looked at how they work with others and how people they care for can stay in touch with family and friends. The CQC asked providers to send examples of changes they made. By sharing examples this may help other providers with the same issues. These are some themes from the examples provided.
  10. Content Article
    The Queen’s Nursing Institute (QNI) has published a major new report on the effect of the COVID-19 pandemic on the UK’s nursing and residential homes.
  11. News Article
    The US Food and Drug Administration (FDA) has approved convalescent plasma for emergency use in hospital patients with COVID-19. The announcement on 23 August said that the FDA had concluded that plasma from recovered patients “may be effective” in treating the virus and that the “potential benefits of the product outweigh the known and potential risks.” The move came despite the absence of results from randomised controlled trials, with only a preprint paper on the effects on hospitalised COVID-19 patients being published to date. Experts have warned that although these early findings show promise there is not enough evidence to show that it works. Plasma from recovered patients was approved on a case by case basis by the FDA for people critically ill with COVID-19 in March. Since then more than 70 000 patients have been treated with plasma. Emergency use approval allows clinicians to use unapproved medical products to diagnose, treat, or prevent serious or life threatening diseases or conditions when there are no adequate, approved, and available alternatives. The FDA’s commissioner, Stephen Hahn, said, “I am committed to releasing safe and potentially helpful treatments for covid-19 as quickly as possible in order to save lives. We’re encouraged by the early promising data that we’ve seen about convalescent plasma. The data from studies conducted this year shows that plasma from patients who’ve recovered from covid-19 has the potential to help treat those who are suffering from the effects of getting this terrible virus.” But Martin Landray, professor of medicine and epidemiology at the University of Oxford and lead researcher for the RECOVERY trial, which is comparing treatments for COVID-19, including convalescent plasma for hospital patients, urged caution. He said, “There is a huge gap between theory and proven benefit. That is why randomised clinical trials are so important. At present, we simply don’t know if it works." Read full story Source: BMJ, 25 August 2020
  12. News Article
    Women working in the NHS are suffering from serious stress and exhaustion in the wake of the coronavirus crisis, a troubling new report has found. Some 75% of NHS workers are women and the nursing sector is predominantly made up of women – with 9 out of 10 nurses in the UK being female. The report, conducted by the NHS Confederation’s Health and Care Women Leaders Network, warns the NHS is at risk of losing female staff due to them experiencing mental burnout during the global pandemic. Researchers, who polled more than 1,300 women working across health and care in England, found almost three quarters reported their job had a more damaging impact than usual on their emotional wellbeing due to the COVID-19 emergency. Read full story Source: The Independent, 25 August 2020
  13. News Article
    The Care Quality Commission's chief executive Ian Trenholm has said he is sceptical about the need to appoint an NHS patient safety commissioner, one of the key recommendations of the recently published Cumberlege review. In a wide-ranging interview with HSJ, Mr Trenholm also revealed that he wants the Care Quality Commission to review the collaboration of every health system in England. Mr Trenholm told HSJ he is “not sure” a patient safety commissioner was needed and that it would need to perform a “role that was different from what’s already in place” for it to add value. He said: “If you look at the work we’re doing on patient safety, the work that HSIB are doing on patient safety, and then we’ve got people within the NHS itself doing work on patient safety, I think there are enough people playing. The question is, are we all working together as effectively as we possibly could be. “If another player helps that work [then] great, but I’m not sure that’s something that is necessary.” Read full story (paywalled) Source: HSJ, 24 August 2020
  14. Content Article
    Dr Steve Barker is joined by Ronald Weinstein, Director/Founder, Arizona Telemedicine Program, and Jeffrey Dunn, Founder/CEO, Redivus Health, to discuss the future of telemedicine within the patient safety and quality improvement space. Telemedicine has become a significant area of investment in recent years and the panelists predict that, in the future, user experience, consolidation, customisation based on relevance to the user, robotics, and health literacy will become top priorities.
  15. News Article
    Theresa May has urged the government to consider “redress” for the victims of a hormone pregnancy test blamed for causing serious birth defects. The former prime minister said that while Primodos victims had received an apology, “lives have suffered as a result” of the drug’s use. In an interview for a Sky News documentary, she praised campaigners who had been “beating their head against a brick wall of the state” which tried to “stop them in their tracks”. A review in 2017 found that scientific evidence did “not support a causal association” between the use of hormone pregnancy tests such as Primodos and birth defects or miscarriage. But Ms May ordered a second review in 2018, because, she said, she felt that it “wasn’t the slam-dunk answer that people said it was”. “At one point it says that they could not find a causal association between Primodos and congenital anomalies, but neither could they categorically say that there was no causal link,” she said. The second review concluded last month that there had been “avoidable harm” caused by Primodos and two other products – sodium valproate and vaginal mesh. An interview for Bitter Pill: Primodos, which will air on Sky Documentaries, Ms May said: “I think it’s important that the government looks at the whole question of redress and about how that redress can be brought up for people. Read full story Source: The Independent, 28 August 2020
  16. Content Article
    To get the safest—and not just the cheapest—devices, the NHS needs to start taking ergonomics seriously, experts say. In March 2020, the UK government commissioned non-medical manufacturers, including Dyson and Renault, to produce ventilators for the excess number of patients expected to have respiratory failure as a result of COVID-19. Because the machines would be used by non-specialist clinicians during the pandemic, NHS England commissioned guidance1 on ergonomic (also known as human factors) design of the ventilators, aimed at achieving “optimum human safety and performance.” However, the commissioning of the ventilator guidance remains an exception rather than the rule. There are, however, signs that the NHS is starting to take human factors seriously—and COVID-19 is a driver.
  17. News Article
    Nursing homes were put under “constant” pressure to accept patients with coronavirus while being regularly refused treatment from hospitals and GPs for residents who became ill at the height of the Covid crisis, a landmark study has found. The Queen’s Nursing Institute said homes were told hospitals had blanket “no admissions” policies during April and May while GPs and local managers imposed unlawful do not resuscitate orders on residents. The findings have emerged in a survey by the QNI, the world’s oldest nursing charity, which surveyed 163 care home nurses and managers working across the country. Carried out between May and June this year, the study establishes an evidence base of the impact on the sector from coronavirus, in addition to the official figures showing care home death rates. One nurse said they were under “constant pressure to admit people who were Covid positive” while another said: “The acute sector pushed us to take untested admissions. The two weeks of daily deaths during an outbreak were possibly the two worst weeks of my 35-year nursing career.” Read full story Source: The Independent, 22 August 2020
  18. Content Article
    Approximately 60-70% of imported respiratory masks are defective and not effective in protecting frontline workers. ECRI offers specialised PPE testing services coupled with customised consultation and recommendations to assist healthcare providers in keeping staff and patients safe. ECRI's N95-Style Mask Testing Program provides assurance on whether masks you have procured or plan to purchase meet industry standards. By testing imported masks, as well as isolation gowns, ECRI is helping healthcare organizations validate products prior to purchase and verify the safety and quality of products already in inventory.
  19. Content Article
    Presentation from Dr Dan Dalton, Consultant Forensic Psychiatrist and National Specialty Advisor for Mental Health, on the legal complexity regarding the use of the Mental Health Act for ensuring compliance with infection control measures.
  20. Content Article
    We all want passionate employees. We want them to care about their jobs and go that extra mile for our company. We also want them to have the confidence to speak up if they think it’s necessary — whether it’s to question a given workplace process or ask a question about the nature of their SMART objectives. Of course, not all employees will stand up and make themselves be heard. So what makes some employees suffer in silence while others are emboldened to stand out from the crowd? The answer is psychological safety. A psychologically safe workplace cultivates a work environment where team members have the freedom to speak out. This environment thrives on mutual respect and encourages co-workers to share their ideas and thoughts without the fear of being shot down or ignored. The obvious effects of psychological safety are better employee wellbeing and mental health. . Stuart Hearn, a performance management specialist, gives his three examples of change that can improve the level of psychological safety in the workplace.
  21. Content Article
    Post-intensive care syndrome (PICS) is a nonspecific syndrome that results from physical, mental, and emotional stresses associated with critical illness and treatment in intensive care units (ICUs). Common features include neuromuscular weakness from immobility, cognitive impairment from sedation, and anxiety, depression, post-traumatic stress syndrome (PTSD), and, as we are learning, additional sequelae for COVID-19 survivors. Symptoms can manifest or persist weeks, months, or years after patient discharge.  This eBook from ECRI provides an overview of PICS, the common danger signs health providers and family members should be able to identify, and its potential long term negative effects. Learn about strategies like creating an ICU diary to help mitigate risks, in addition to understanding other recommendations to consider to protect the safety and well-being of patients during their recovery.
  22. Content Article
    The Re-Engineered Discharge (RED) Toolkit helps re-design the discharge process using health literacy and patient safety strategies. Research showed that the RED was effective at reducing readmissions and post-hospital emergency department visits. The RED Toolkit includes templates for easy-to-understand discharge instructions and post-discharge telephone calls, and guidance on delivering the RED to diverse populations. This is part of AHRQ's health literacy improvement tools to help healthcare organisations, leaders and professionals improve health literacy.
  23. Content Article
    The highly publicised crashes of two Boeing 737 Max aircraft quickly triggered pointed questions about the company’s commitment to safety versus profits. As we near the twentieth anniversary of the landmark Institute of Medicine (IOM) report on medical error, To Err is Human, that same level of scrutiny should apply to hospitals.  Cost-benefit analysis is both a legitimate and crucial management function. But the criteria used in those calculations can range from appropriate to appalling. It’s long past time to examine how the “business case for safety” can sometimes represent a serious threat to patients’ lives. Michael L. Millenson discusses the dangers in the "business case" for patient safety in his blog in Health Affairs.
  24. News Article
    Safety inspectors have ordered a mental health trust to make immediate improvements after visiting two inpatient wards where three patients died inside six months. The Care Quality Commission this week warned Devon Partnership Trust it would take “urgent action” over “serious concerns about patients” unless the trust made the required improvements swiftly. The watchdog inspected the trust’s Delderfield and Moorland wards in June following concerns about three patient deaths in September, October and March, along with “a number of” patient safety incidents - including ligature incidents. The CQC also highlighted poor patient observation routines and a lack of learning from previous incidents, amid delays in completing investigations into safety incidents. Read full story Source: HSJ, 21 August 2020
  25. News Article
    A majority of pregnant women who died from coronavirus during the peak of the pandemic were from an ethnic minority background, it has emerged. A new study of more than a dozen women who died between March and May this year also heavily criticised the reorganisation of NHS services which it said contributed to poor care and the deaths of some of the women. This included one woman who was twice denied an intensive care bed because there were none available, as well as women treated by inexperienced staff who had been redeployed by hospitals and who made mistakes in their treatment of the women. The report, by experts at the National Perinatal Epidemiology Unit, based at the University of Oxford, also criticised mental health services after four women died by suicide. The report said women were “bounced” between services which had stopped face-to-face assessments during the crisis. The report looked at 16 women’s deaths in total. Eight women died from COVID-19, seven of whom had an ethnic minority background. Two women with Covid-19 died from unrelated causes, four died by suicide and two were victims of homicide. In the report, published on Thursday, the authors concluded improvements in care could have been made in 13 of the deaths they examined. In six cases, improvements in care could have meant they survived. Read full story Source: The Independent, 21 August 2020
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