Patient Safety Learning

Join Animah Kosai, Founder of Speak Up at Work, Roger Kline, Trustee Patients First UK, and Kernan Manion Executive Director, Center for Physician Rights as we explore essential crisis communication principles to ensure staff safety, healthcare team cohesion, and effective care delivery. Few in our local and national communities have ever experienced a pandemic causing complete shutdown and emergency isolation measures. With such an immense and unparalleled global catastrophe, despite play-acting disaster drills, few corporations are truly prepared for the emergency response demands and the accompanying requirement for a Crisis Response Mindset and its communication principles. Fortunately, wisdom gleaned from knowledge-based science and on-the-ground experience in prior epidemics and natural catastrophes is available to guide us through this very unfamiliar turf. A particular focus is on intra-organisational crisis management and communication with an aim toward sharing best practices. Further information

Acute trusts have been told to set aside 15% of their daily coronavirus tests for NHS key workers who are quarantining at home with others. New guidance for NHS trust chief executives on covid-19 testing has been published after NHS England chief executive Sir Simon Stevens announced hundreds of frontline staff would be given antigen tests from next week. The guidance from NHSE said acute trusts should prioritise testing staff working in critical care, emergency departments and ambulance services, along with “any other high priority groups you determine locally”. Read full story (paywalled) Source: HSJ, 30 March 2020

A breathing aid that can help keep coronavirus patients out of intensive care has been created in under a week. University College London engineers worked with clinicians at UCLH and Mercedes Formula One to build the device, which delivers oxygen to the lungs without needing a ventilator. Continuous Positive Airway Pressure (CPAP) devices are already used in hospitals but are in short supply. China and Italy used them to help Covid-19 patients. Forty of the new devices have been delivered to ULCH and to three other London hospitals. If trials go well, up to 1,000 of the CPAP machines can be produced per day by Mercedes-AMG-HPP, beginning in a week's time. The Medicines and Healthcare products Regulatory Agency (MHRA) has already given its approval for their use. Read full story Source: BBC News, 30 March 2020

Hundreds of thousands of pregnant women face a crisis as maternity and abortion services shut their doors because of the coronavirus outbreak. One MP this weekend warned that pregnant women were being treated like “second-class citizens” with the closure of NHS services and a lack of government guidance for those in need of urgent care. The NHS faces a severe shortage of midwives with the number of unstaffed positions doubling to one in five since the virus arrived in Britain. A fifth (22%) of senior midwives said their local maternity units had shut indefinitely because of staff self-isolating or being deployed elsewhere. Read full story (paywalled) Source: The Times, 29 March 2020

The NHS could have prevented “chaos and panic” had the system not been left wholly unprepared for the pandemic, the editor of the BMJ has said. Numerous warnings were issued but these were not heeded, Richard Horton wrote in the Lancet. He cited an example from his journal on 20 January, pointing to a global epidemic: “Preparedness plans should be readied for deployment at short notice, including securing supply chains of pharmaceuticals, personal protective equipment, hospital supplies and the necessary human resources to deal with the consequences of a global outbreak of this magnitude.” Horton wrote that the government’s Contain-Delay-Mitigate-Research plan had failed. “It failed, in part, because ministers didn’t follow WHO’s advice to ‘test, test, test’ every suspected case. They didn’t isolate and quarantine. They didn’t contact trace." “These basic principles of public health and infectious disease control were ignored, for reasons that remain opaque. The result has been chaos and panic across the NHS.” Read full story Source: Guardian, 28 March 2020

National and regional NHS chiefs will seek to share out scarce ventilators to ”areas with the most immediate need, on a fair share basis relative to patient ventilation need," they have told hospital chiefs, who are increasingly concerned about what they will receive and when. Many are expecting demand for ventilated beds to outstrip what they have as the number of patients seriously ill with covid-19 ramps up. Trust leaders yesterday told HSJ they were growing increasingly worried about the lack of information over when the machines would be sent to their trusts. Some are worried London, and other regions which see their demand spike first, will get more supply. A letter from NHS England and Improvement to trust chiefs late on Wednesday told them that as “extra ventilators become available we will coordinate distribution via regional teams who will work with local health systems”. Read full story (paywalled) Source: HSJ, 27 March 2020

Shared by Carola Martino, MD Risk Manager and Hospital Disaster Manager, Teaching Hospital of Pisa, and GRC Team at Clinical Risk Management and Patient Safety Centre, Tuscany Region on the Global Patient Safety Network Today our memory went back to 2016 when the Ebola epidemic was in final stage after devastating several Western African countries. At that time just isolated cases or secondary infections occurred outside Africa. At that time what we were seeing in Africa was not a problem that would have interested high resources countries. At that time, in 2016, we were working with WHO to be appointed WHO Collaborating Center and we were studying carefully all the documents that WHO was producing for supporting countries and healthcare systems in getting ready for an emergency, toolkit for evaluating the preparedness of our systems, checklists for evaluating logistics and medical devices and human resources, plans for community engagement. Plans for "war" have to be defined, tested, simulated, spread, adapted during "peace" time. But at that time pandemic or health emergency were problems that did not have anything to do with us. Our risk manager and Hospital Disaster Manager, Doctor Carola Martino that is now working for managing the emergency and the related risks in the Teaching Hospital of Pisa underlines:” You need to exercise your mind to be able to adapt quickly to manage changes, we need to anticipate in time this exercise because in all these situations, time is the only resource that we will no longer be able to recover. This organizational strategy needs a structured method and lots of training and simulations. So we must take this commitment if we want all this experience not to be lost” One very practical example of managing in different way during the emergency concerns the PPE management. This critical resource must be managed with a centralized approach, underlines Doctor Carola Martino. Infact, at the very beginning of the emergency there was no a single coordination line, or a centralized control of the PPE nor any national guideline that reflected international indications for the most appropriate use of PPE. It is fundamental in each hospital to have a specific procedure and a centralized point of distribution to manage PPE in order not to waste basic equipment that is precious and scarce during the emergency. This is a small and practical example of different way of thinking during an emergency situation. We believe that for the future to come, our communities of experts in the field of risk management, human factor and ergonomic, quality and safety of care and public health should play all together an important role from the very beginning, from the time of peace. Another challenge at the moment is adapting our reporting and learning systems in new ways of tracing information for detecting system weaknesses and barriers to overcome. We have to respond to the situation and react as soon as possible to be resilient. Human factors principles can be a guide to coordinate interactions among different stakeholders of the emergencies, simulation sessions the way to learn how to act together when the scenario become real. We also believe that when the emergency will arrive to an end a profound reflection will have to be done on what really means global health, on what really means one health. May be this scaring crisis will be the opportunity to think again about this.

The absence of COVID-19 testing for NHS staff is causing huge workforce shortages by forcing doctors to self-isolate even if they do not have the virus, the head of the BMA has warned. The government’s advice is for people with COVID-19 symptoms to stay at home for seven days, but for all other household members who remain well to isolate for 14 days. The BMA council chairman, Chaand Nagpaul, said that the lack of testing for staff was “counter-intuitive” as it was likely to be forcing more staff than necessary to stay away from hospitals and GP surgeries because they do not know if they are infected. Read full story (paywalled) Source: BMJ, 27 March 2020

NHS staff who have contracted coronavirus but remain at work because they show no symptoms are probably infecting patients, a public health official admitted yesterday. Doctors said they were worried about becoming “part of the problem” owing to a lack of testing and a shortage of protective equipment, particularly outside hospitals. Masks, gloves and visors can help stop people infecting others and stop them becoming infected. The British Medical Association said that staff testing was urgently needed so that doctors and nurses knew if it was safe for them to see patients. Read full story (paywalled) Source: The Times, 27 March 2020

A pandemic was predictable but instead of paying billions in insurance we’ve allowed a disaster that could cost trillions... Read full story (paywalled) Source: The Times, 25 March 2020

The government says a communications mix-up meant it missed the deadline to join an EU scheme to get extra ventilators for the coronavirus crisis. Ministers were earlier accused of putting Brexit before public health when Downing Street said the UK had decided to pursue its own scheme. But No 10 now says officials did not get emails inviting the UK to join and it could join future schemes. The party's shadow Health Secretary Jonathan Ashworth said: "Given the huge need for PPE, testing capacity and crucial medical equipment including ventilators, people will want to know why on Monday ministers were saying they had 'chosen other routes' over the joint EU procurement initiatives but now they are claiming that they missed the relevant emails. "We need an urgent explanation from ministers about how they will get crucial supplies to the frontline as a matter of urgency." Read full story Source: BBC News, 27 March 2020

Data collected via the NHS's 111 telephone service is to be mixed with other sources to help predict where ventilators, hospital beds, and medical staff will be most in need. The goal is to help health chiefs model the consequences of moving resources to best tackle the coronavirus pandemic. Three US tech firms are aiding the effort - Amazon, Microsoft and Palantir - as well as London-based Faculty AI. The plan is expected to be signed off by Health Secretary Matt Hancock. "Every hospital is going to be thinking: Have we got enough ventilators? Well we need to keep ours because who knows what's going to happen - and that might not be the optimal allocation of ventilators," explained a source in one of the tech companies involved. "Without a holistic understanding of how many we've got, where they are, who can use them, who is trained, where do we actually have patients who need them most urgently, we risk not making the optimal decisions." Read full story Source: BBC News, 26 March 2020

Join the Institute for Healthcare Improvement's (IHI's) President Emeritus and Senior Fellow, Donald M. Berwick MD, MPP, FCRP and IHI President and CEO, Derek Feeley for a special Virtual Learning Hour today on Mobilizing to Respond to COVID-19. In this hour-long call, Don and Derek will share key learnings, innovations, and revelations they’ve been gathering and gleaning from health care leaders and improvers across the globe. The call will also serve as an opportunity for listeners to share the struggles, stories, and bright spots they are seeing in this unprecedented time. Register

A family from East Sussex may have been Britain’s first coronavirus victims, catching the virus in mid-January after one of them visited an Austrian ski resort that is now under investigation for allegedly covering up the early outbreak. If confirmed by official tests, it would mean the outbreak in Britain started more than a month earlier than currently thought. As things stand, the first recorded UK case was on January 31, and the earliest documented incidence of transmission within Britain occurred on 28 February. Mark Woolhouse, a professor of infectious disease epidemiology at the University of Edinburgh, said cases like this demonstrated the need for widespread antibody and viral genome sequencing testing. These tests can show who has and has not been exposed to the virus, and therefore help epidemiologists trace the history and spread of the illness. "A really significant unknown in this epidemic is whether or not the cases that are symptomatic are simply the tip of the iceberg," he said. "If there are hidden cases in large numbers, then it tells us that the infection is more difficult to control than we thought… but it also suggests that there is a possibility herd immunity may have built up." Read full story Source: The Telegraph, 25 March 2020

New guidelines for assessing people with coronavirus who go to hospital were amended after an outcry from parents of children with special needs. The emergency guidelines published by the National Institute for Health and Care Excellence (NICE) are designed to help determine how much treatment a patient will receive. Those deemed "completely dependent for personal care for whatever reason" will be offered end-of-life care rather than restorative treatment. This now excludes people with learning difficulties or cerebral palsy. In a statement NICE said the system was "not perfect" but was designed to support hospital medics "during this very difficult period of intense pressure". "We welcome the recent clarification that the Clinical Frailty Score should not be used in certain groups," it said. The updated guidelines now state that it "may not perform as well in people with stable long-term disability" and suggests that it is not used in those cases. Read full story Source: BBC News, 26 March 2020