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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Across the country there have been reports of “do not resuscitate” (DNR) orders being imposed on patients with no consultation, as is their legal right, or after a few minutes on the phone as part of a blanket process. Laurence Carr, a former detective chief superintendent for Merseyside Police, is still angry over the actions of doctors at Warrington Hospital who imposed an unlawful “do not resuscitate” order on his sister, Maria, aged 64. She has mental health problems and lacks the capacity to be consulted or make decisions and has been living in a care home for 20 years. As her main relative, Mr Carr found out about the notice on her records only when she was discharged to a different hospital a week later. Maria had been admitted for a urinary tract infection at the end of March. Although she has diabetes and an infection on her leg her condition was not life threatening. Mr Carr said: “My sister has no capacity to effectively be consulted due to her mental illness and would not understand if they did try to explain, so I was furious that I had not been consulted." He later learnt that the reason given by the hospital for imposing the DNR was "multiple comorbitidies". In a statement, Warrington and Halton Teaching Hospitals Foundation Trust said it was fully aware of the law, which was reflected in its policies and regular training. It said: “We did not follow our own policy in this case and have the requisite discussions with the family. The template form which was completed in this case indicates that discussion with the family was ‘awaiting’. Regretfully due to human error this did not occur." Mr Carr and his sister are not alone. National charity Turning Point said it had learnt of 19 inappropriate DNARs from families, while Learning Disability England said almost one-fifth of its members had reported DNARs placed in people’s medical records without consultation during March and April. Read full story Source: The Independent, 14 July 2020
  2. News Article
    Five NHS trusts in the South West have been ordered to make immediate improvements after the death of a 20-year-old prisoner who needed healthcare. Lewis Francis was arrested in Wells, Somerset, in 2017 after stabbing his mother while “acutely psychotic” and taken into custody. Although his condition mandated a transfer to a medium secure mental health hospital, there was “no mechanism” in place to move Mr Francis and he was taken to prison, where he died by suicide two days later, according to a coroner. Contributory factors to his death included “insufficient collaboration, communication and ownership between and within organisations… together with insufficient knowledge of… the Mental Health Act,” according to Nicholas Rheinberg, the assistant coroner for Exeter and Greater Devon. In a Prevention of Future Deaths report, Mr Rheinberg said a memorandum of understanding was in place for the transfer of “mentally ill prisoners direct from police custody” in the West Midlands, and he called on the South West Provider Collaborative to agree a similar deal with “relevant organisations and agencies”. Read full story (paywalled) Source: HSJ, 14 July 2020
  3. News Article
    Only two out of 23 recommendations from a royal college review into a trust’s troubled maternity services can be shown to be fully implemented, a new investigation has revealed. A learning and review committee, set up by East Kent Hospitals University Foundation Trust, found that 11 more of the recommendations from a 2016 review by the Royal College of Obstetricians and Gynaecologists (RCOG) were “partially” implemented. But it said there was either no evidence the remaining 10 had been delivered, or there was evidence they were not implemented. The original RCOG review looked at a number of cases where babies had died as well as broader issues within the maternity service at the trust. The committee was set up after an inquest into the death of Harry Richford, who died a week after his birth in 2017 at the trust’s Queen Elizabeth, the Queen Mother, Hospital in Thanet. Many of the issues which came to light at his inquest echoed those from the RCOG report. Committee chair Des Holden, medical director of Kent Surrey Sussex Academic Health Science Network, highlighted the difficulties in tracking evidence and action plans during a time when the trust had significant changes in leadership. But he said the committee felt cases where evidence could not be found or the standard of evidence gave concern, the recommendations could not be said to be met. Derek Richford, Harry’s grandfather, said on behalf of the family: “We are saddened and shocked to find that over four years after the RCOG found fundamental systemic failings and made 23 recommendations, only two have been completed. It is not good enough for them to now say ‘leadership has changed’. The main board must take responsibility and be held to account.” Read full story (paywalled) Source: HSJ, 13 July 2020
  4. News Article
    A wide disparity in coronavirus mortality rates has emerged in English hospitals, with data seen by the Guardian showing that one hospital trust in south-west England had a death rate from the disease of 80% while in one London trust it was just 12.5%. The figures, which NHS England has compiled but never published, show the age-standardised mortality rates that all of the country’s 135 acute hospital trusts have recorded during the pandemic. Doctors regard age as the single biggest predictor or risk factor for dying from COVID-19. They cover the period from the start of the coronavirus crisis in March, through its peak in late March and April, up until 15 May, by which time 42,850 (85%) of the 50,219 deaths so far in all settings had occurred in England and Wales. It is the first such data to emerge about how many people have lived or died in each trust after being treated there because they had been left critically ill by the disease. They are based on patients who were treated in an intensive care or high-dependency unit or on a ward. Senior doctors said the dramatic gap in death rates of 67.5 percentage points between the trusts with the highest and lowest rates was notable and may mean that some hospitals needed to learn lessons from others. Read full story Source: Guardian, 14 June 2020
  5. Content Article
    SBAR is an easy to use, structured communication format that enables information to be transferred accurately between individuals. SBAR stands for 'Situation, Background, Assessment, Recommendation' and was originally developed in the milatary context to create a reliable consistent process to facilitate concise, clear, focused communication. SBAR communication is normally very focused and relatively brief. Most SBARs are around one page of A4, two at most. The aim is to convey the critical information in an understandable way, clearly and succinctly. The SBAR tool has also been widely used by healthcare teams as a focused way of transferring information about a person's condition.
  6. Content Article
    The Model for Improvement is a simple yet powerful tool for accelerating improvement. The model is not meant to replace change models that organizations may already be using, but rather to accelerate improvement.
  7. Content Article
    A project charter is the statement of scope, objectives and people who are participating in a project.
  8. Content Article
    Over 300 health and social care staff died in the UK during the first COVID‐19 wave. There are concerns regarding infection risks but there has been very little discussion or research on personal protective equipment (PPE) design. To understand how PPE changes clinical tasks, Hignett et al. conducted an online survey between (via Twitter, LinkedIn, etc.) 4 April and 8 May 2020, when there was a peak of 33,173 deaths. They focused on human factor/ergonomic issues to avoid preconception bias about availability to ask with regard to fit and comfort, reading and operating equipment, hearing and communicating, reaching and moving, and dexterity to use touch screens, press buttons, open vials/taps and use syringes.
  9. Content Article
    Safety of patients and surgical teams is paramount when undertaking elective surgery in the initial recovery phase from COVID-19. This tool from the Royal College of Surgeons of England lists key considerations to minimise risks of patients and surgical teams contracting COVID-19 in the hospital.
  10. Content Article
    Hospitals are currently planning to resume or expand surgical services that were cancelled during the recent COVID-19 crisis. While emergency surgery will need to continue to be performed within current restrictions, other operations might now be feasible as resources become available. The following checklist from the Royal College of Surgeons of England introduces some of the main criteria that should be taken into account in the initial stages of resuming planned surgery.
  11. Content Article
    Clinical decisions rarely occur in isolation. We must consider the social contexts in clinical environments and draw on theories of social emotion to help us better understand the influence of others’ emotion on our own thoughts, feelings and, ultimately, our ability to deliver safe care. In their Editorial in BMJ Quality & Safety, Jane Heyhoe and Rebecca Lawton explorie the role of social emotion in patient safety and looks at the recent research in this emerging area. They call on the patient safety community to embrace the idea that emotions and emotional contexts exert important impacts on healthcare delivery. Characterising these impacts will inform strategies for supporting staff and delivering safer and more effective care to patients.
  12. News Article
    Some NHS trusts in England are yet to complete /cOVID-19 risk assessments for their staff from ethnic minority groups more than two months after the NHS first told them to do so, an investigation by The BMJ has found. On 29 April NHS England’s chief executive, Simon Stevens, wrote to all NHS leaders telling them to carry out risk assessments and make “appropriate arrangements” to protect ethnic minority staff, amid growing evidence that they were at greater risk of contracting and dying from COVID-19. However, The BMJ asked England’s 140 acute care trusts for details of risk assessments they had carried out and what subsequent actions they had put in place. Seventy trusts responded. Of these, 27 (39%) said that assessments were yet to be completed for all ethnic minority staff, and 43 (61%) indicated that assessments had been completed. But the other 70 trusts were unable to provide a response within the 20 day deadline, citing “unprecedented challenges” posed by the COVID-19 pandemic, so it is not known what stage they are at in risk assessing staff. Commenting on The BMJ’s findings, Chaand Nagpaul, the BMA’s chair of council, said, “Clearly, we know that a significant number of doctors have not been risk assessed. It is a shame that it has taken so long, because the risk assessments and mitigations would have been most useful and impactful during the peak of the virus.” Doctors’ leaders have suggested that systemic race inequalities in the workplace may have exacerbated delays in risk assessing staff. Nagpaul said, “The BMA survey found that doctors from a BAME [black, Asian, and minority ethnic] background felt under more pressure to see patients without adequate protection. So it does beg the question of whether there’s also been this added factor of BAME healthcare staff feeling unable to demand their right to being assessed and protected." “This is something the NHS needs to tackle. This is an issue that predates covid. It’s vital that we have an NHS where anyone is able to voice their concerns. No one should have to suffer or have fear in silence.” Read full story Source: The BMJ, 10 July 2020
  13. News Article
    A former senior NHS official plans to sue the organisation after he had to pay a private hospital £20,000 for potentially life-saving cancer surgery because NHS care was suspended due to COVID-19. Rob McMahon, 68, decided to seek private treatment after Worcestershire Acute Hospitals NHS trust told him that he would have to wait much longer than usual for a biopsy. He was diagnosed with prostate cancer after an MRI scan on 19 March, four days before the lockdown began. McMahon was due to see a consultant urologist on 27 March but that was changed to a telephone consultation and then did not take place for almost two weeks. “At that appointment, the consultant said: ‘Don’t worry, these things are slow-growing. You’ll have a biopsy but not for two or three months.’ I thought, ‘that’s a long time’, so decided to see another consultant privately for a second opinion.” A PET-CT scan confirmed that he had a large tumour on both lobes of the prostate and a biopsy showed the cancer was at risk of breaking out of the prostate capsule and spreading into his body. He then paid to undergo a radical prostatectomy at a private Spire hospital. “This is care that I should have had on the NHS, not something that I should have had to pay for myself. I had an aggressive cancer. I needed urgent treatment – there was no time to waste,”, he said. “With the pandemic, he added, “it was almost like a veil came down over the NHS. He worked for the NHS for 17 years as a manager in hospitals in London, Birmingham and Redditch, Worcestershire, and was the chief executive of an NHS primary care trust in Leicester.” Mary Smith of Novum Law, McMahon’s solicitors, said: “Unfortunately, Rob’s story is one of many we are hearing about from cancer patients who have been seriously affected by the disruption to oncology services as a result of COVID-19." Read full story Source: The Guardian, 11 July 2020
  14. News Article
    Coronavirus patients have continued to suffer from fatigue, breathlessness and forgetfulness more than 100 days after contracting the bug. Many COVID-19 survivors have found that they are not back to normal months after they tested positive. Louise Nicholls, from Litherland in Liverpool, is one of those people who found themselves suffering from curious symptoms long after she should have been back to normal. She was told she had coronavirus by her doctor on 1 April having gone in search of medical help after suffering from a number of respiratory symptoms. "I was trying to do my workouts and I was getting really short of breath," Louise said. "I couldn't put my finger on what was going on but it got worse every day. My chest started getting tighter and my lungs were burning. I didn't have a cough or a fever but I had shortness of breath and I was waking up with night sweats." Louise said her symptoms were dismissed as anxiety by those around her at first, but when her symptoms got worse she phoned the doctor who said it sounded like coronavirus. Louise said: "My doctor said it sounds like covid. She said 'you're young and fit, you'll be over it in a few weeks' and sent me on my way." Louise's breathing continued to get worse and she was given a steroid inhaler, which she is still taking today. Although Louise feels much better than she did at one time, she is still struggling with her breathing today and is continuing to use her inhaler. She said: "I feel much better than I was but I can't push myself too much... My chest feels tight if I don't take my inhaler every day." Read full story Source: Mirror, 12 July 2020
  15. News Article
    Doctors may be missing signs of serious and potentially fatal brain disorders triggered by coronavirus, as they emerge in mildly affected or recovering patients, scientists have warned. Neurologists are on Wednesday publishing details of more than 40 UK COVID-19 patients whose complications ranged from brain inflammation and delirium to nerve damage and stroke. In some cases, the neurological problem was the patient’s first and main symptom. The cases, published in the journal Brain, revealed a rise in a life-threatening condition called acute disseminated encephalomyelitis (Adem), as the first wave of infections swept through Britain. At UCL’s Institute of Neurology, Adem cases rose from one a month before the pandemic to two or three per week in April and May. One woman, who was 59, died of the complication. “We’re seeing things in the way Covid-19 affects the brain that we haven’t seen before with other viruses,” said Michael Zandi, a senior author on the study and a consultant at the institute and University College London Hospitals NHS foundation trust. “What we’ve seen with some of these Adem patients, and in other patients, is you can have severe neurology, you can be quite sick, but actually have trivial lung disease,” he added. Read full story Source: The Guardian, 8 July 2020
  16. Content Article
    The Prioritisation Matrix is a structured visual tool to help you decide which improvement ideas to test first and how to focus your activity and energy. It works best in a collaborative environment and can help to build buy-in and communicate why you have chosen to test certain ideas before others. They come in many different forms, but the simplest and easiest to use is the 2 x 2 matrix. The axis of the matrix are usually labelled to enable you categorize the priority of each change idea. Usually the horizontal axis is labelled with a concept such as “effort” or “willingness to adopt”. The vertical axis is usually “impact” or “value”.
  17. Content Article
    This is a simple tool that helps you to understand the time you have available for your main work activity, e.g. seeing patients or managing a service. It is an excel spreadsheet that calculates this for you if you enter the time spent on various activities. When analysing and planning capacity, it’s important to look at time available for people to do the work required. This means understanding how much time people can actually spend on the required tasks. The tool provides a helpful way to understand this for individuals and teams and therefore can help plan work and improve productivity.
  18. Content Article
    Cause and effect is a diagram-based technique that helps you identify all of the likely causes of the problems you're facing.
  19. Content Article
    Plan Do Study Act (PDSA) cycles are an ideal quality improvement tool that can be used to test an idea by temporarily trialling a change and assessing its impact.
  20. Content Article
    A driver diagram visually presents a team's theory of how an improvement goal will be achieved.
  21. Content Article
    Stakeholder analysis is a way of identifying, prioritising and understanding your stakeholders. It is an interest/influence grid with four quadrants. It enables you to plot or map stakeholders based on their level of interest (high/low) and level of influence (high/low). Where you plot a stakeholder guides the actions you should take for involving and communicating with them.
  22. Content Article
    A measurement plan sets out details for each measure proposed for an improvement project.
  23. Content Article
    A Pareto chart is a type of bar chart in which the factors that contribute to an overall effect are arranged in order from most frequent to least. This ordering helps identify the "vital few" — the factors that warrant the most attention. It also includes a line showing the cumulative % (so you can see easily for example that the top three causes account for 80% of incidents). According to the "Pareto Principle," in any group of things that contribute to a common effect, relatively few account for the majority of the effect.
  24. Content Article
    This Royal College of General Practitioners (RCGP) report calls on the four governments of the UK to each produce a comprehensive plan to support GPs in managing the longer-term effects of COVID-19 in the community.
  25. Content Article
    Out-patient Parenteral Antibiotic Therapy (OPAT) is now a routine part of care in the UK following demonstration that it is safe and effective for patients and OPAT is now being actively promoted as part of the UK government’s stewardship initiatives. NHS North Tees and Hartlepool share their experience of redesigning their OPAT services. See the attachment below for details on the project. 
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