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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    This toolkit has been produced by the National Tracheostomy Safety Project in collaboration with the Academic Health Science Networks in response to the COVID-19 pandemic, to support healthcare staff who are looking after this very vulnerable group of patients. Primarily it is for those working in hospitals. However, much of the material is also applicable to primary and community care settings. Wherever it is used, the toolkit’s key objective is the same: to ensure that healthcare staff caring for patients with tracheostomies in these challenging circumstances are able to do so safely. 
  2. Content Article
    The British Thoracic Society has published the results of their 2019 national audit of acute non-Invasive ventilation (NIV) in adult patients in NHS hospitals.   Data were collected in 2019, before the pandemic, and the audit did not look at things such as pandemic preparedness or numbers of NIV hardware available, but at the quality of the service provided. The audit analysed data provided from over 150 hospitals, for a total of over 3500 patient records, and looked for adherence to our quality standards in the provision of the service.
  3. News Article
    Matt Hancock has ordered an urgent review into how Public Health England (PHE) calculates daily COVID-19 death figures. It comes after scientists said they believed PHE was “over-exaggerating” the daily coronavirus death toll, by counting people if they die of any cause at any time after testing positive for the disease. Professor Yoon K Loke, of the University of East Anglia, and Carl Heneghan, professor of evidence-based medicine at the Nuffield Department of Primary Care, said on Thursday night that a “statistical flaw” in the way PHE compiles data on deaths created a disparity in figures published by the different UK nations. “It seems that PHE regularly looks for people on the NHS database who have ever tested positive, and simply checks to see if they are still alive or not,” they wrote. “PHE does not appear to consider how long ago the Covid test result was, nor whether the person has been successfully treated in hospital and discharged to the community. Anyone who has tested Covid-positive but subsequently died at a later date of any cause will be included on the PHE Covid death figures.” Read full story Source: The Independent, 17 July 2020
  4. News Article
    There are "deep concerns" for brain injury survivors after many reported losing rehabilitation services during the COVID-19 lockdown. A survey by the charity Headway found 57% of people, injured since 2018, had seen face-to-face services stopped. The first two years of recovery are crucial in regaining skills, such as talking, with fears this could affect future independence. The government acknowledged it had been "a challenging time". Headway conducted its survey across all brain injury rehab services, with 1,140 respondents. It found about 60% of those were frustrated by the situation, their anxiety and depression had increased and they felt more socially isolated. Read full story Source: BBC News, 17 July 2020
  5. News Article
    The list is a dismal and shameful one - Mid-Staffordshire, Morecambe Bay, the rogue surgeon Ian Paterson, maternity care at the Shrewsbury and Telford. All are patient safety scandals involving tragic stories of life-changing mistreatment of patients and, in some cases, the loss of loved ones. Pledges have been made that patient safety will be put front and centre of health policy. New regulators have been put in place. But now yet another review has found the health system in England to be "disjointed, siloised and defensive" and that the culture needs a shake-up. It has called for a new patient safety champion with legal powers to be put in place. The plan is to have an individual with "real standing" outside and independent of the system, accountable to the parliamentary Health and Social Care Select Committee. The Commissioner would be expected to take up and investigate patient complaints where appropriate, and hold organisations to account - the review had stated that the failure of health authorities to respond to concerns was a recurrent theme. Read full story Source: BBC News, 8 July 2020
  6. News Article
    The hospital trust which has been recording the largest number of covid deaths for several weeks has asked NHS England and NHS Improvement for help with infection control. East Kent Hospitals University Foundation Trust is also getting help from the Kent and Medway Clinical Commissioning Group, including a senior infection control and prevention nurse who is now working with the trust. It has seen persistently high numbers of covid deaths at a time when most other trusts have seen them dwindle to nothing or almost nothing. In the week to 10 July, it had 18 deaths – 9.5% of the national total. In a statement to HSJ yesterday the trust said it had “recently asked for support from NHS England and NHS Improvement to strengthen our infection prevention and control resource”. It said it had also introduced “a strict ‘front door’ policy, limiting the number of people on site, taking temperature checks before people enter the building, providing face masks and hand washing facilities”; begun testing asymptomatic staff; and regularly testing asymptomatic patients. Read full story (paywalled) Source: HSJ, 16 July 2020
  7. News Article
    RLDatix, the leading provider of intelligent patient safety solutions, have announced a new framework—Applied Safety Intelligence™—that will tighten the relationship between patient safety and risk management by moving the industry from a retrospective review of adverse events toward a future of proactive prevention. This profound shift will usher in a new era of future-forward patient safety. Traditionally, patient safety and risk management efforts have been driven by a retrospective capture of harmful events, often resulting in long wait times to reach resolutions for patients and families, hefty litigation and punitive damages to health systems, and a profound negative impact on the care teams involved. With Applied Safety Intelligence, healthcare organisations will be able to reduce preventable harm and, in many cases, avoid it altogether. "As the global leader in patient safety, RLDatix is unmatched in its ability to drive innovation that leads to safer care," said Jeff Surges, CEO of RLDatix. "With Applied Safety Intelligence, we are putting patient and caregiver safety at the center of value-based care as we continue challenging traditional conventions around inevitable harm, provider burnout and enterprise risk. Together with our customers, we are catalysing a future where the human and financial impact of unsafe care is significantly reduced. " Read full story Source: CISION PR Newswire, 15 July 2020
  8. Content Article
    The government-commissioned review, First Do No Harm, into why mesh implants and other treatments were allowed to harm hundreds of women said the failings were “caused and compounded by failings in the health system itself”. HSJ's Health Check podcast considers why it is being buried by government. 
  9. Content Article
    Providing patients with access to electronic health records (EHRs) may improve quality of care by providing patients with their personal health information, and involving them as key stakeholders in the self-management of their health and disease. With the widespread use of these digital solutions, there is a growing need to evaluate their impact, in order to better understand their risks and benefits, and to inform health policies that are both patient-centred and evidence-based. The main objective of this systematic review from Neves et al. was to assess the impact of these interventions on the six dimensions of quality of care. The findings suggest that providing patients with access to EHRs can improve patient safety and effectiveness
  10. News Article
    The latest annual report into the deaths of people with learning disabilities has criticised the “insufficient” national response to past recommendations and called for “urgent” policy changes. The national learning disabilities mortality review programme has criticised the response from national health bodies to its previous recommendations. To date, just over 7,000 deaths have been notified to the programme and reviews have been completed for just 45%. There have been four annual reports for programme to date, and in the latest published today, the authors warned: “The response to these recommendations has been insufficient and we have not seen the sea change required to reassure [families] that early deaths are being prevented." “It is long over-due that we should now have concerted national-level policy change in response to the issues raised in this report and previous others. A commitment to take forward the recommendations in a meaningful and determined way is urgently required.” The latest report also warns that black, Asian and ethnic minority children with learning disabilities die “disproportionately” younger compared to other ethnicities. It also found system problems and gaps in service provision were more likely to contribute to deaths in BAME people with learning disabilities. Read full story Source: HSJ, 16 July 2020
  11. News Article
    The Royal College of Obstetricians and Gynaecologists ( (RCOG) has today launched a Race Equality Taskforce to better understand and tackle racial disparities in women’s healthcare and racism within the obstetric and gynaecology workforce. Addressing health inequalities is a key priority area for RCOG President Dr Edward Morris, who is co-chairing the Taskforce alongside Dr Ranee Thakar, Vice President of the RCOG, and Dr Christine Ekechi, Consultant Obstetrician & Gynaecologist and RCOG Spokesperson for Racial Equality. Statistics show, for example, that black women are five times more likely to die in pregnancy, childbirth or in the six-month postpartum period compared with White women and the risk for Asian women is twice as high. During the pandemic, 55% of pregnant women admitted to hospital with coronavirus were from a Black, Asian or other minority ethnic background despite the fact 13% of the UK population identify themselves as BAME. It is also clear that there is a significant gap in understanding the factors that result in a higher risk of morbidity and mortality for Black, Asian and other ethnic minority women in the UK. The Taskforce will collaborate with groups across healthcare and government as well as individual women to address these concerning trends and will ensure that the work of the RCOG is reflective of its anti-racist agenda. Read full story Source: RCOG, 15 July 2020
  12. Content Article
    Last year, a report from the Health Foundation looked at quality measurement—including patient experience—across a range of healthcare services. It described a “measurement maze”, with multiple sources and numerous national bodies presiding over data collection. The potential usefulness of the data for trusts was “limited by the data being hard to locate online, with multiple spreadsheets to choose from and large Excel workbooks to download and navigate.” The Patient Experience Library wanted to find a solution to this, to find a way to organise all the data such that every Trust could get one-click access to everything it might need.. Miles Sibley, Director of the Patient Experience Library, explains what they did.
  13. News Article
    A hospital trust at the centre of Britain’s largest ever maternity scandal has widespread failings across departments and is getting worse, the care regulator has warned as it calls for NHS bosses to take urgent action. Ted Baker, chief inspector of hospitals, urged NHS England to intervene over the “worsening picture” at Shrewsbury and Telford Hospital Trust, which is already facing a criminal investigation. There are as many as 1,500 cases being examined after mothers and babies died and were left with serious disabilities due to poor care going back decades in the trust’s maternity units. Now, in a leaked letter seen by The Independent, Prof Baker has warned national health chiefs that issues are still present today across wards at the trust – with inspectors uncovering poor care in recent visits that led to “continued and unnecessary harm” for patients. He raised the prospect that the Care Quality Commission (CQC) could recommend the trust be placed into special administration for safety reasons, which has only been done once in the history of the NHS – at the former Mid Staffordshire NHS Trust, where a public inquiry found hundreds of patients suffered avoidable harm and neglect because of widespread systemic poor care. In a rarely seen intervention, Prof Baker’s letter to NHS England’s chief operating officer, Amanda Pritchard, warned there were “ongoing and escalating concerns regarding patient safety” and that poor care was becoming “normalised” at the trust, which serves half a million people with its two hospitals – the Royal Shrewsbury and Telford’s Princess Royal. Read full story Source: The Independent, 16 July 2020
  14. News Article
    The initial data on a trial of the coronavirus vaccine being developed by Oxford University will be released in the coming week, The Lancet medical journal has announced amid reports its findings have been promising. The development of a vaccine to fight against the virus has been touted as pivotal in returning the world to life as it was before the pandemic by protecting vulnerable people and building up immunity among populations. Now Oxford University’s contribution - one of the world’s leading candidates for a viable vaccine – is understood to have made promising results in initial testing. Read full story Source: The Independent, 16 July 2020
  15. News Article
    Every child in Scotland will need additional mental health support as a consequence of measures taken to tackle the coronavirus crisis, according to the country’s children and young people’s commissioner. Speaking exclusively to the Guardian as he publishes Scotland’s comprehensive assessment of the impact of the pandemic on children’s rights – the first such review undertaken anywhere in the world – Bruce Adamson said the pandemic had sent a “very negative” message about how decision-makers value young people’s voices. He said Scotland has been viewed as a children’s rights champion but that efforts to involve young people in the dramatic changes being made to their education and support “went out the window as soon as lockdown came along”. There have been escalating concerns across the UK about children’s mental health after support structures were stripped away at the start of lockdown. Earlier this week, the Guardian revealed that five children with special educational needs have killed themselves in the space of five months in Kent, amidst warnings over the impact of school closures on pupils. Read full story Source: The Guardian, 16 July 2020
  16. Content Article
    This study from Sanko et al., published in Simulation in Healthcare, found that improvements in systems thinking increase adverse event (AE) reporting patterns among undergraduate nursing students participating in a simulation exercise. The authors suggest that prelicensure training include reinforcement of systems thinking principles to achieve patient safety improvements.
  17. Content Article
    The objective of this systematic review from Kuitunen et al., in the Journal of Patient Safety, was to identify systemic defenses (such as barcode scanning) to confirm drug and patient identity, clinical decision systems, and smart infusion pumps) to prevent in-hospital intravenous (IV) medication errors. Of the 46 included studies, most discussed systemic defenses related to drug administration; fewer discussed defenses during prescribing, preparation, treatment monitoring and dispensing. Closed loop medication management and smart pumps were the most common systemic defenses examined in the included studies The authors identify a need for further studies exploring the effectiveness of different combinations of systemic defenses.
  18. News Article
    Around 5000 fewer people were admitted to hospitals in England for acute coronary syndrome than expected from January to the end of May this year, an analysis has shown. The results, published in the Lancet, indicate that many patients have missed out on lifesaving treatments during the COVID-19 outbreak. This decline started before the UK lockdown began on 23 March and “was qualitatively similar throughout the country, with only minor variations … in different demographic groups,” the authors wrote. Among patients admitted to hospital with acute myocardial infarction there was a “sustained increase in the proportion ... receiving [a percutaneous coronary intervention (PCI) for acute myocardial infarction] on the day of admission and a continued reduction in the median length of stay,” they added. “The reduced number of admissions … is likely to have resulted in increases in out-of-hospital deaths and long-term complications of myocardial infarction and missed opportunities to offer secondary prevention treatment for patients with coronary heart disease,” they concluded. Read full story Source: BMJ, 15 July 2020
  19. News Article
    Trials of new systems to prevent overcrowding in emergency departments ahead of a potential second wave of COVID-19 in the winter are taking place at hospitals in Portsmouth and Cornwall and are due to shortly be expanded to other areas, with Dorset and Newcastle likely sites, HSJ can reveal. London is also experimenting with introducing the system, having pulled back from an earlier proposal to roll it out it rapidly, shortly after the COVID-19 peak. In the trials, NHS 111 has acted as a “triage point” enabling patients not facing medical emergencies but needing urgent treatment to book access to primary care, urgent treatment centres or same-day emergency “hot clinics” staffed by specialists. Patients are discouraged from attending without an appointment, but they are able to do so; and sources said performance targets would continue to apply to them, although these were already subject to review pre-covid. Both the Royal College of Emergency Medicine and NHSE are now hopeful a new triage system for emergency care can be in place by the winter. Read full story (paywalled) Source: 15 July 2020
  20. News Article
    The NHS is losing more than 3.5 million days of work because of staff sickness linked to mental health problems, it has emerged. New data from NHS England shows the problem is getting worse with an increasing number of days and proportion of staff off sick for mental health reasons. The data runs from March 2019 to February 2020, before the coronavirus crisis. It is feared the pandemic could lead to lasting mental health issues for some NHS workers. Layla Moran, a Liberal Democrat MP who obtained the data through a parliamentary question, said: “These incredibly worrying figures show the mental health of NHS workers was already at a tipping point before the pandemic struck." Read full story Source: The Independent, 14 July 2020
  21. News Article
    Health Secretary Matt Hancock admits he is "worried" about the long-term impacts of coronavirus on those who have been infected. Mr Hancock said a "significant minority" of people had suffered "quite debilitating" conditions after contracting COVID-19. It comes after Sky News reported on how psychosis, insomnia, kidney disease, spinal infections, strokes, chronic tiredness and mobility issues are being identified in former coronavirus patients in northern Italy. Asked about the long-term impact of the disease on patients, the health secretary told Sky News: "I am concerned there's increasing evidence a minority of people - but a significant minority - have long-term impacts and it can be quite debilitating. "So we've set up an NHS service to support those with long-term impacts of COVID-19 and, also, we've put almost £10m into research into these long-term effects." Read full story Source: Sky News, 15 July 2020
  22. News Article
    Waiting lists for treatment in 2019 were at record levels, with the proportion of patients waiting less than 18 weeks for treatment at its lowest level in a decade. Cancer waiting times were the worst on record, with 73% of trusts not meeting the 62-day cancer target. Waiting for diagnostic tests was at the highest level since 2008: 4.2% of patients were waiting over six weeks against a target of less than 1%. On 17 March 2020, NHS England and NHS Improvement asked trusts to postpone all non-urgent elective operations to free up as much inpatient and critical care capacity as possible. At this point, there were 4.43 million people on waiting lists for consultant-led elective treatment. It is imperative that we open a national debate on what the NHS can deliver in a resource-constrained environment. To translate into action, this must involve patients, clinicians, system and regional leaders, the public and politicians. Such a debate is long overdue: current methods for prioritising elective care, such as referral to treatment or the 62-day cancer standard, are no longer fit for purpose. Read full story (paywalled) Source: HSJ, 14 July 2020
  23. Content Article
    A group of doctors who have chronic COVID-19 symptoms have been digesting information on social media platforms from thousands of individuals in the UK and worldwide affected by covid symptoms for 16 weeks or more. Some of these symptoms and patients’ experiences have been summarised in a video “Message in a bottle—long covid SOS.” The announcement of an NHS portal for patients who have been admitted to hospital or dealt with the illness at home is a welcome signal that the problems of long standing covid symptoms are starting to be recognised. In this BMJ article, the authors explore these patients' experiences and urge that the new NHS portal should be co-created with by patients with COVID-19 and carers. There needs to be some bidirectionality in the creation of this service and subsequent research to avoid institutional “top down” blind spots about the condition.
  24. News Article
    The NHS have duped thousands of women into believing the most common incontinence mesh operation is safe, by not adding loss of sex life into its risk figures, campaigners say. The move keeps figures low so surgeons can reassure women that it is a safe day case operation. The discovery is buried in a report from five years ago, and when questioned on it, the MHRA, tasked with making sure implants are safe for patients, passed the buck and blamed the report authors. The revelation comes after a debate in Westminster, where health minister Jackie Doyle Price said there was not enough evidence to suspend the plastic implants and quoted a risk of 1-3%. However, those figures were blown out of the water just weeks before the debate in a landmark study using the NHS’s own hospital re-admission figures which show TVT mesh tape risk is at least 10%. Campaigners say even that is not a reflection of the true scale of the mesh disaster because it does not take into account women going to doctors for pain medication or those suffering in silence. Read full story Source: Cambs Times, 31 October 201t
  25. News Article
    People with non-life threatening illnesses will be told to call before going to Wales' biggest A&E department. Patients will be assessed remotely and given a time slot for the University Hospital of Wales in Cardiff if needed. Hospital bosses feel returning to over-crowded waiting rooms would provide an "unacceptable" risk to patients due to coronavirus. The system is set to start at the end of July, but will not apply to people with serious illnesses or injuries. Details are still being discussed by Cardiff and Vale health board, but patients with less serious illnesses or injuries will be told to phone ahead, most likely on the 24-hour number used to contact the local GP out-of-hours service. They will be assessed by a doctor or a nurse and, depending on the severity of the condition, will either be given a time window to go to A&E or be directed to other services. This system was introduced in Denmark several years ago. "This is all about being safe and ensuring that emergency medicine and emergency care is safe and not about putting barriers in place to those more vulnerable people," says the department's lead-doctor Dr Katja Empson. "What we really think is that by using this system, we'll be able to focus our attention on those vulnerable groups when they do present." If successful, the system could become a long-term answer to reducing pressures on emergency medicine, she added. Read full story Source: BBC News, 14 July 2020
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