Jump to content
 View Profile  See their activity

  • Posts

    11,589

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

Everything posted by Patient Safety Learning

  1. Content Article
    Sodium nitrite has one licensed indication: as an antidote to cyanide poisoning. The Royal College of Emergency Medicine (RCEM) and National Poisons Information Service (NPIS) guideline recommends that it should be “immediately available in the emergency department”. Sodium nitrite can cause significant side effects and is categorised as ‘highly toxic’. Historically, sodium nitrite 30mg/ml has been an unlicensed product supplied in ampoules by ‘Specials’ manufacturers. However a licensed product, supplied as a vial, has been available since 2016. The National Reporting and Learning System (NRLS) identified two incidents where unlicensed sodium nitrite was inadvertently administered to premature babies instead of sodium bicarbonate 4.2%: one very premature baby died soon after this incident occurred and the other died after a period of neonatal intensive care. Hospitals have been given until 6 November to physically check all wards for the wrong drug and to destroy any unlicensed sodium nitrite supplies. This alert is an action for all acute trusts (children and adult).
  2. News Article
    Trusts are being encouraged to adopt a system in which patients initiate follow up appointments by the lastest guidance from NHS England designed to help the NHS recover from the covid crisis. It is hoped the approach can reduce unnecessary demand and therefore help trusts cut waiting lists that have soared as a result of the restrictions placed on hospital activity during the pandemic. Under 'patient initiated follow up' (PIFU) patients decide when they require follow up appointments. They are given guidance as to what symptoms and other factors they should take into account when deciding if a follow up appointment is necessary. PIFU is already used by some trusts, but it has not yet become widely adopted. The plan to increase PIFUs was set out in a guidance published today designed to underpin the “phase three letter” sent out to NHS leaders last week. The guidance, Implementing phase 3 of the NHS response to COVID-19 pandemic , says “individual services should develop their own guidance, criteria and protocols on when to use PIFUs”. The document also sets out some overarching principles. It says services will be rated against the following headline metrics: “total number and proportion of patients on the PIFU pathway; patient outcomes, e.g. recovery rates, relapse rates; waiting times; and DNA rates”. Read full story (paywalled) Source: HSJ, 7 August 2020
  3. News Article
    Policymakers’ failure to tackle chronically underfunded social care has resulted in a “lost decade” and a system now at breaking point, according to a new report. A team led by Jon Glasby, a professor of health and social care at the University of Birmingham, says that without swift government intervention including urgent funding changes England’s adult social care system could quickly become unsustainable. Adult social care includes residential care homes and help with eating, washing, dressing and shopping. The paper says the impact has been particularly felt in services for older people. Those for working-age people have been less affected. It suggests that despite the legitimate needs of other groups “it is hard to interpret this other than as the product of ageist attitudes and assumptions about the role and needs of older people”. Read full story Source: The Guardian, 9 August 2020
  4. Content Article
    Drawing on a 2010 analysis of the reform and costs of adult social care commissioned by Downing Street and the UK Department of Health, this paper from Glasby et al., published in the Journal of Social Policy, sets out projected future costs under different reform scenarios, reviews what happened in practice from 2010-19, explores the impact of the growing gap between need and funding, and explores the relationship between future spending and economic growth. It identifies a ‘lost decade’ in which policy makers failed to act on the warnings which they received in 2010, draws attention to the disproportionate impact of cuts on older people (compared to services for people of working age) and calls for urgent action before the current system becomes unsustainable.
  5. Content Article
    Steve defines whistleblowing as "To raise concerns; talk to trusted colleagues; rise it with the team; follow your employer’s and national policies / processes; involve managers". In this blog, he proposes that whistleblowing isn’t a problem to be solved or managed, but an opportunity to learn and improve. The more we move away from labelling and stereotyping the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and reconciliation.
  6. Content Article
    The International Electrotechnical Commission (IEC) is a worldwide organisation for standardisation comprising all national electrotechnical committees (IEC National Committees). The object of IEC is to promote international co-operation on all questions concerning standardisation in the electrical and electronic fields. This part of IEC 62366 specifies a process for a manufacturer to analyse, specify, develop and evaluate the usability of a medical device as it relates to safety. This usability engineering (human factors engineering) process permits the manufacturer to assess and mitigate risks associated with correct use and use errors, i.e., normal use. It can be used to identify but does not assess or mitigate risks associated with abnormal use.
  7. Content Article
    When a patient's safety is compromised, or even if someone just comes close to having an incident, you need to know you are taking the right measures to address it, now and in the future. The Canadian Patient Safety Institute (CPSI) provides you with practical strategies and resources to manage incidents effectively and keep your patients safe. This integrated toolkit considers the needs and concerns of patients and their families, and how to properly engage them throughout the process. Drawn from the best available evidence and expert advice, this newly designed toolkit is for those responsible for managing patient safety, quality improvement, risk management, and staff training in any healthcare setting.
  8. Content Article
    Older people and people with an intellectual disability who receive long-term care are considered particularly vulnerable to infection outbreaks, such as the current coronavirus pandemic. The combination of healthcare concerns and infection-related restrictions may result in specific challenges for long-term care staff serving these populations during infection outbreaks. This review from Embregts et al. aimed to: (1) provide insight about the potential impact of infection outbreaks on the psychological state of healthcare staff and (2) explore suggestions to support and protect their psychological well-being. They found that research into support for long-term care staff during an infection outbreak is scarce. Without conscious management, policy and research focus, the needs of this professional group may remain underexposed in current and future infection outbreaks. The content synthesis and reflection on it in this article provide starting points for new research and contribute to the preparation for future infection outbreaks.
  9. Content Article
    The Safer Healthcare Now! campaign was launched in 2005 and provides interventions to raise awareness and facilitate implementation of best practices to support patient safety improvement in Canada. The interventions serve as a resource for frontline healthcare providers, healthcare organisations, and health quality committees and councils. This Canadian Patient Safety Institute (CPSI) web page provides information, resources, and tools you can put into practice to identify, prevent, and learn from patient safety incidents.
  10. News Article
    A senior coroner has demanded action by Simon Stevens, chief executive of NHS England, to ensure that GPs monitor repeat prescriptions properly, after an 84 year old man with dementia died from an overdose of tramadol. Peter Cole, who was found collapsed at his home in Welwyn in Hertfordshire by a neighbour, had amassed a large quantity of unused prescription drugs at his house. He had numerous drugs on repeat prescription, said Geoffrey Sullivan, chief coroner for Hertfordshire. Read full story (paywalled) Source: BMJ, 5 August 2020
  11. News Article
    The NHS will be inflicting pain, misery and risk of death on tens of thousands of patients if it again shuts down normal care when a second wave of COVID-19 hits, doctors’ and surgeons’ leaders are warning. They are urging NHS bosses not to use the same sweeping closures of services that were introduced in March to help hospitals cope with the huge influx of patients seriously ill with Covid. “The NHS must never again be a Covid-only service. There is a duty to the thousands of patients waiting in need and in pain to make sure they can be treated,” said Prof Neil Mortensen, president of the Royal College of Surgeons of England. The leader of Britain’s doctors warned that hospitals should not leave patients “stranded” by again suspending a wide range of diagnostic and treatment services. “We cannot have a situation in which patients are unable to access diagnostic tests, clinic appointments and treatment which they urgently need and are simply left stranded,” said Dr Chaand Nagpaul, chair of council at the British Medical Association (BMA). Read full story Source: The Guardian, 6 August 2020
  12. News Article
    Hundreds of thousands of NHS patients could lose the ability to see their GP face to face because their doctors may have to protect themselves from coronavirus. An analysis by the Health Foundation charity has found around a third of GPs who run their practice on their own are at high risk from the virus themselves. If they are forced to abandon face-to-face consultations the charity warned it could deny 710,000 patients access to their doctor. Dr Rebecca Fisher, senior policy fellow at the Health Foundation and a GP said: “The ongoing risk of Covid-19 to the safety of both patients and GPs means hundreds of thousands of people may find it much harder to get a face-to-face GP appointment. “It’s particularly worrying that GPs at higher risk from Covid-19 are far more likely to be working in areas of high deprivation. Those are precisely the areas with the greatest health need, the biggest burden from Covid-19, and an existing under-supply of GPs relative to need. Unless urgent action is taken this could become another way in which poorer communities become further disadvantaged, and risks further widening health inequalities.” Read full story Source: The Independent, 6 August 2020
  13. News Article
    Fifty million face masks bought by the government in April will not be used in the NHS because of safety concerns. The government says the masks, which use ear-loop fastenings rather than head loops, may not fit tightly enough. They were bought for healthcare workers from supplier Ayanda Capital as part of a £252m contract.Ayanda says the masks meet the specifications the government had set out. The government says its safety standards process is "robust". According to legal papers seen by the BBC, the government says these masks will now not be used in the NHS because of a safety issue. The document says that there is concern about whether they would fit adequately. To be effective these types of face mask need to fit tightly to create a seal between the mask and the wearer's face. Anyone who wears them for work is required to undergo a face fit test. "The face fit is either a pass or a fail and there are more fails on products with ear loops than there are on products with head harnesses," says Alan Murray, chief executive of the British Safety Industry Federation. Read full story Source: BBC News, 6 August 2020
  14. News Article
    All medical students at the National University of Singapore will be taught patient safety through a virtual reality (VR) game, a move prompted by the COVID-19 social distancing rules. The game, called PAtient Safety aS Inter-Professional Training (PASS-IT), will use VR to get all 1,500 of them acquainted with the proper procedures in operating theatres. It was developed by the NUS Yong Loo Lin School of Medicine (NUS Medicine). The school has 12 such VR stations. Each has a 15-minute game with various medical scenarios that will require the students to "act out" the standard operating procedures. These range from how to check for a patient's consent and verify their identity as well as the correct ways to handle surgical tools and what must be done if a team member accidentally cuts himself. "This VR system is a good tool to help the students consolidate their learning despite increased clinical restrictions," said Associate Professor Alfred Kow, assistant dean of education of NUS Medicine. Read full story Source: The Straits Times, 5 August 2020
  15. News Article
    The parliamentary committee led by Jeremy Hunt will subject health ministers to a “CQC style ratings system”, as part of a new way of scrutinising the Department of Health and Social Care. The Health and Social Care Select Committee has set out plans for a new ratings system to “offer independent and objective evaluation of ministerial pledges”. This will mean the government is held to account by an evaluation process similar to that used across the NHS and social care system which gives not just an absolute score but key pointers as to how to improve that score next time round. “We hope it will focus attention on areas such as cancer, mental health and patient safety where a number of vital commitments have been made,” says Jeremy Hunt, committee chair and former health secretary. In his six year tenure as health secretary, Mr Hunt styled himself as a champion of patient safety, while his successor, Matt Hancock, has been criticised for appearing to jettison this agenda. Read full story (paywalled) Source: HSJ, 5 August 2020
  16. Content Article
    Jerome Groopman is a doctor who discovered that he needed a doctor. When his hand was hurt, he went to six prominent surgeons and got four different opinions about what was wrong. Groopman was advised to have unnecessary surgery and got a seemingly made-up diagnosis for a nonexistent condition. Groopman, who holds a chair in medicine at Harvard Medical School, eventually found a doctor who helped. But he didn't stop wondering about why those other doctors made the wrong diagnoses. You can listed or read his interview from the link below.
  17. Content Article
    Concerns for patient safety persist in clinical oncology. Within several nonmedical areas (eg, aviation, nuclear power), concepts from Normal Accident Theory (NAT), a framework for analysing failure potential within and between systems, have been successfully applied to better understand system performance and improve system safety. Clinical oncology practice is interprofessional and interdisciplinary, and the therapies often have narrow therapeutic windows. Thus, many of the processes are, in NAT terms, interactively complex and tightly coupled within and across systems and are therefore prone to unexpected behaviours that can result in substantial patient harm. To improve safety at the University of North Carolina, Chera et al. have applied the concepts of NAT to their practice to better understand their systems’ behaviour and adopted strategies to reduce complexity and coupling. Furthermore, recognising that you cannot eliminate all risks, they have stressed safety mindfulness among their staff to further promote safety. Many specific examples are provided herein. The lessons from NAT are translatable to clinical oncology and may help to promote safety.
  18. Event
    until
    East London NHS Foundation Trust (ELFT) Quality Improvement (QI) Department is hosting a one-day Pocket QI training. This is an interactive easy to follow introduction to some of the concepts and methods of QI. Join a team of Improvement Advisors who will take you through the fundamentals of QI and how you can make apply the methodology to your personal and professional life. Training will be delivered by ‘Zoom’ video conferencing. Registration
  19. Content Article
    Proactive patient safety and risk prevention are key to helping healthcare organisations survey and mitigate global and local risks. Jeff Surges, Chief Executive Officer of RLDatix, explores this in his blog for Health Europa.
  20. Content Article
    Cancer is the leading cause of death in the UK, and cancer doesn’t just stop because of a pandemic. Before COVID-19 there were around 367,000 new cases of cancer in the UK and, sadly, around 165,000 deaths. Early diagnosis followed by swift access to the most effective treatment remains as important as ever for survival. It is also essential to preserve cancer patients’ quality of life through a personalised, holistic approach to their care. Over 2 million people were estimated to be waiting for cancer screening, testing and treatment. In addition to this, many cancer patients may have been asked to shield, causing immediate disruption to daily life including not being able to see family and friends or do food shopping. In response to this crisis, Cancer Research UK conducted a survey aiming to understand the impact of COVID-19 on cancer patients’ testing, treatment and care, day-to-day lives and wellbeing, and support for government policies. 
  21. Content Article
    PSNet publish a case of a misdiagnosed pelvic mass in a pregnant woman with an accompanying commentary from Leiserowitz and Hedriana discussing the diagnostic errors and the systems change needed.
  22. News Article
    Plans for a mass expansion of rehabilitation beds in new “Seacole centres” have been scrapped, with local leaders now told there is no capital funding to build them. In late May, NHS England announced the “first” Seacole Centre in Surrey, for patients recovering from coronavirus, and asked other local systems to draw up proposals for similar units ahead of a possible second peak of the virus over winter. The policy was designed to provide significant extra bed capacity to help get covid and other respiratory patients out of hospital more quickly, while offering effective rehab care. But multiple well-placed sources have now told HSJ that capital bids for new Seacole units have been rejected. In a statement, NHSE said: “Work with local NHS and social care providers suggests that these expanded rehab services can largely be provided in existing physical facilities as well as people’s own homes, so government has not allocated extra capital in year for this purpose.” However, local leaders told HSJ that some of the plans to use “existing physical facilities” still required some capital funding to make them suitable for rehab care. One trust executive in the North West said: “If there’s no capital it means we can’t go ahead.” Read full story (paywalled) Source: HSJ, 5 August 2020
  23. News Article
  24. Content Article
    Research has shown that there is variability in quality of life (QOL) outcomes for people with intellectual disabilities who live in group homes. The aim of this study from Humphreys et al. was to examine dimensions of group home culture as predictors of QOL outcomes.
  25. News Article
    As part of a £160m initiative, the NHS will look to roll out and expand ‘Covid-friendly’ cancer treatments which are safer for patients during the pandemic, the health service’s Chief Executive Sir Simon Stevens has announced. The funding will help pay for drugs which treat patients without having as significant of an impact on their immune system, or which could offer other benefits such as a reduced number of hospital visits. Almost 50 treatments have been approved for use as ‘swaps’ for existing drugs, with thousands of patients having already benefitted, and more are expected to be made available this week as part of deals struck between the NHS and pharmaceutical companies. Within these treatments include options which allow patients to take tablets at home or receive medicines with fewer side effects rather than undergoing hospital-based treatment which can leave them more susceptible to coronavirus and other infections. Sir Stevens said: “Since the first case of Covid in England six months ago, NHS staff have fast tracked new, innovative ways of working so that other services, including A&E, cancer and maternity could continue safely for patients and it is thanks to these incredible efforts that 65,000 people could start treatment for cancer during the pandemic. “We are now adopting new, kinder treatment options which are not only effective but safer for use during the Covid-19 pandemic and more convenient for thousands of patients, who can take medication at home or be given medicines with less harmful effects on their immune system.” Read full story Source: National Health Executive, 3 August 2020
×
×
  • Create New...