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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    This innovative, practical guide introduces researchers to the use of the video reflexive ethnography in health and health services research. This methodology has enjoyed increasing popularity among researchers internationally and has been inspired by developments across a range of disciplines: ethnography, visual and applied anthropology, medical sociology, health services research, medical and nursing education, adult education, community development, and qualitative research ethics.
  2. News Article
    A major London hospital has declared a “critical incident” due to a surge in patients with coronavirus, with one senior director in the capital calling the development “petrifying”. In a message to staff, Northwick Park Hospital in Harrow said it has no critical care capacity left and has contacted neighbouring hospitals about transferring patients who need critical care to other sites. The message, sent last night and seen by HSJ, said: “I am writing to let you know that we have this evening declared a ‘critical incident’ in relation to our critical care capacity at Northwick Park Hospital. This is due to an increasing number of patients with Covid-19. “This means that we currently do not have enough space for patients requiring critical care. “As part of our system resilience plans, we have contacted our partners in the North West London sector this evening to assist with the safe transfer of patients off of the Northwick Park site” Read full story (paywalled) Source: HSJ, 20 March 2020
  3. News Article
    A campaign to reduce stillbirths, brain injury, and avoidable deaths in babies has failed to have any effect in the past three years, findings from the Royal College of Obstetricians and Gynaecologists show. The president of the college, Edward Morris, has urged maternity units across the UK to learn from the latest report and act on its recommendations. “We owe it to each and every person affected to find out why these deaths and harms occur in order to prevent future cases where possible,” he said. Read full story (paywalled) Source: BMJ, 19 March 2020
  4. Content Article
    Each Baby Counts is a national quality improvement programme led by the Royal College of Obstetricians and Gynaecologists (RCOG) to reduce the number of babies who die, or are left severely disabled, as a result of incidents occurring during term labour. The Each Baby Counts programme brings together the results of local investigations into stillbirths, neonatal deaths and brain injuries occurring during term labour to understand the bigger picture, share the lessons learned and prevent babies from dying or suffering brain injuries in the future. This report presents key findings and recommendations based on the analysis of data relating to the care given to mothers and babies throughout the UK, to ensure each baby receives the safest possible care during labour.
  5. News Article
    NHSX is working on a contact tracking app to trace the spread of coronavirus through the population. Contact tracking is already in limited use for people who have tested positive and the discipline has a long history in tuberculosis outbreaks. In a statement sent to HSJ, Matthew Gould, Chief Executive of NHSX, said : “NHSX are looking at whether app-based solutions might be helpful in tracking and managing coronavirus, and we have assembled expertise from inside and outside the organisation to do this as rapidly as possible.” Read full story (paywalled) Source: HSJ, 18 March 2020
  6. News Article
    Social care has a vital part to play in the fight against Covid-19, but without proper support more lives will be put at risk, says Vic Rayner, Executive Director of the National Care Forum. "We are working round the clock to keep the people we care for safe and happy and to protect our staff. We know the COVID-19 situation is moving fast – but the care sector can only effectively play its part with more direct support from the government." Social care providers, like many across the country, are working hard to prepare for the escalation of COVID-19. This includes refresher training on infection control, robust measures to ensure any visitors to care services are safe to enter, planning for how to keep going in the face of significant workforce shortages, and ensuring the people they care for and their staff are kept safe and well. However, it is clear that social care is in urgent need of help, more directly and more quickly, to meet the needs of the most vulnerable, or to ensure that their staff are adequately protected. The issue of protection is never far from care providers’ minds, and the lack of personal protective equipment (PPE) for care staff remains a pressing problem. Read full story Source: The Guardian, 20 March 2020
  7. News Article
    Several trust procurement leads have expressed frustration with the government’s response to covid-19, with HSJ being told of shortages of crucial personal protective equipment, unpredictable deliveries and a lack of clarity from the centre NHS Supply Chain, which procures common consumables and medical devices for trusts, has been “managing demand” for an increasing number of PPE and infection control products for since the end of February to ensure “continuity of supply”. Some products, like certain polymer aprons, are unavailable altogether because of the increased demand and disrupted supply caused by the covid-19 outbreak. One procurement lead told HSJ: “They aren’t supplying enough, they aren’t fulfilling orders. It’s completely chaotic.” Another said his trust had “just enough to manage for the time being.” Read full story (paywalled) Source: HSJ, 20 March 2020
  8. Community Post
    Are you a patient with an issue not related to the coronavirus, and yet facing new challenges because of it? Understandably the healthcare system is currently focusing its attention on the deadly effects of the coronavirus, so the need to pay attention to patient safety is now more important than ever. We’re asking for patients, carers, family members and friends to share their stories, highlight weaknesses or safety issues that need to be addressed and share solutions that are working. We’re looking for people to share with us: What have you noticed that has been different since the crisis started? (e.g., outpatient appointments, collection of medication, GP appointments, cancellation of operations). Whether you have had an elective intervention or appointment postponed? (Do you know the warning signs to call for help? Is there a hotline or urgent clinic for you to contact?). Has anything improved since the crisis? (e.g., has the use of digital/virtual interventions (accessing a GP) had a positive effect). Read a summary of this initiative here. If you are a member of the hub, just reply to this topic below. If you're not already a member of the hub, it's quick and free to join. Register here. We will be identifying themes and reporting to healthcare leaders with your insights. We want to help close the gaps that might emerge as everyone focuses on the pandemic.
  9. Content Article
    As we study the numbers on the coronavirus cases and the deaths related to COVID-19, a similar question comes up again and again: Why is the coronavirus causing so many more deaths in Italy than in other countries? In this article, published in Medium, Andreas Backhaus, an Economist, discusses the demographics and why they are a warning to other countries.
  10. News Article
    COVID-19 is stable for several hours to days in aerosols and on surfaces, according to a new study from National Institutes of Health, CDC, UCLA and Princeton University scientists in The New England Journal of Medicine. The scientists found that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detectable in aerosols for up to three hours, up to four hours on copper, up to 24 hours on cardboard and up to two to three days on plastic and stainless steel. The results provide key information about the stability of SARS-CoV-2, which causes COVID-19 disease, and suggests that people may acquire the virus through the air and after touching contaminated objects. The findings affirm the guidance from public health professionals to use precautions similar to those for influenza and other respiratory viruses to prevent the spread of SARS-CoV-2: Avoid close contact with people who are sick. Avoid touching your eyes, nose, and mouth. Stay home when you are sick. Cover your cough or sneeze with a tissue, then throw the tissue in the trash. Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe. Read full story Source: National Institutes of Health, 17 March 2020
  11. Content Article
    Clinically focused presentation on Oliver's story from Steve Turner, given to the NICE Medicines & Prescribing Associates on 1 May 2019.
  12. Content Article
    The Learning Disabilities Mortality Review (LeDeR) Programme is a world-first. It is the first national programme of its kind aimed at making improvements to the lives of people with learning disabilities. The University of Bristol is one of the partners in the programme, which is funded and run by NHS England. Reviews of deaths are being carried out with a view to improve the standard and quality of care for people with learning disabilities. People with learning disabilities, their families and carers have been central to developing and delivering the programme. Further information and useful resources can be found on the University of Bristol's website.
  13. Community Post
    Is the language used by officials describing the coronavirus pandemic dehumanising those with underlying health conditions and making us feel we no longer matter? In a blog published in the Guardian, Kathryn Hearn says the UK government’s treatment of the coronavirus outbreak has in effect written off all of us with health issues.
  14. Content Article
    In a blog published in the Guardian, Kathryn Hearn says the UK government’s treatment of the coronavirus outbreak has in effect written off all of us with health issues. The language used by officials describing the spiralling scenarios risks dehumanising us, and makes us feel we no longer matter, Kathryn explains. NHS England’s latest report on the health of the nation acknowledged that 43% of adults – that’s nearly 20 million people – ­­­are living with at least one long-term health condition. Although not all of those would be directly in danger from Covid-19, there’s still a major section of our society who will be. You’ll know somebody, for sure. Until Monday’s U-turn, the UK government’s policy was to manage rather than to contain the virus - which would have allowed close to a quarter of a million people to die. Allowing Covid-19 to spread throughout the population in the hope of building some “herd immunity” among the youngest, fittest and healthiest "felt irresponsible at best, and callous at worst". 
  15. Content Article
    The objective of this investigation was to understand the context of magnetic resonance imaging (MRI) scanning under general anaesthetic and how care may be reasonably adjusted for patients with autism or learning disabilities. The ‘reference event’ was Alice, a teenage girl who had autism. Sadly, Alice died following her MRI scan under general anaesthetic. The findings and conclusions of this investigation may be applicable to other non-invasive procedures carried out on patients who are under general anaesthetic.
  16. News Article
    A “collective failure” to appreciate the enormity of the coronavirus pandemic and enact swift measures to protect the public will lead to unnecessary deaths, according to a leading doctor who says the UK ignored clear warning signs from China. Richard Horton, the Editor-in-Chief of the Lancet, rounded on politicians and their expert advisers for failing to act when Chinese researchers first warned about a devastating new virus that was killing people in Hubei eight weeks ago. The team from Wuhan and Beijing reported in January that the number of deaths was rising quickly as the virus spread in China. They urged the global community to launch “careful surveillance” in view of the pathogen’s “pandemic potential”. Horton said nothing in the science had changed since January. “The UK’s best scientists have known since that first report from China that Covid-19 was a lethal illness. Yet they did too little, too late,” he said. While the UK was now taking the right actions to quell the outbreak, Horton said, in due course “there must be a reckoning” where difficult questions would have to be asked and answered. “We have lost valuable time. There will be deaths that were preventable. The system failed,” he said. Read full story Source: The Guardian, 18 March 2020
  17. Content Article
    Many practices are now using or considering using alternatives to face-to-face consultations because of concerns about COVID-19. Important new information and guidance is now available to support video consultations. Produced by researchers at the University of Oxford, this document is packed with extremely useful, practical advice and tips to help doctors,other primary care clinicians, and patients navigate these almost uncharted waters at a time of unprecedented challenge for the health service.
  18. Content Article
    South London and Maudsley NHS Foundation Trust and St Guy's and St Thomas' NHS Foundation Trust have put together this occupational health advice for their staff based on current published advice from Public Health England.
  19. News Article
    St Bartholomew’s Hospital is to be the emergency electives centre for the London region as part of a major reorganisation to cope with the coronavirus outbreak. Senior sources told HSJ the London tertiary hospital, which is run by Barts Health Trust, will be a “clean” site providing emergency elective care as part of the capital’s covid-19 plan. It is understood the specialist Royal Brompton and Harefield Foundation Trust will also be taking some emergency cardiac patients. The news follows NHS England chief executive Sir Simon Stevens telling MPs on Tuesday that all systems were working out how best to optimise resources and some hospitals could be used to exclusively treat coronavirus patients in the coming months. Read full story (paywalled) Source: HSJ, 18 March 2020
  20. News Article
    Draper & Dash, a leading predictive patient flow provider, has launched a COVID-19 live hospital planning and demand impact assessment tool. The company said it has been working around the clock to deliver its vital tool to support impact assessment. It allows trusts to view and analyse national Hospital Episode Statistics (HES) data, alongside a number of live data sources on COVID-19 cases by the minute, as they emerge across the globe. The system models the impact of increased volume and complexity at a local and system level, providing visibility of ICU, theatres, and overall bed impact, and connects this live information to each trust’s clinical workforce. The tool shows immediate impacts on beds and staff under a range of selected scenarios. Read full story Source: Health Tech Newspaper, 18 March 2020
  21. Content Article
    The authors of this paper describe here the content and structure of their patient registry along the Standards for Quality Improvement Reporting Excellence (SQUIRE) with the aim of transparent in-house quality monitoring, communication with patients, and also to facilitate benchmarking with other neurosurgery health care providers.
  22. News Article
    The rapid spread of coronavirus has given the NHS a “kick forward” in the need to accelerate technology and ensure staff are digitally prepared, a GP has said. Neil Paul, a Digital Health columnist and GP in Ashfields, said the need to reduce face-to-face appointments to prevent the potential transmission of Covid-19 has forced the NHS, particularly in primary care, to adopt already available technologies. He said practices “still in the stone ages” and “technophobes” were less prepared for the current situation, but that it would force them to move into the digital age. “It’s absolutely made my surgery go ‘right, how do we do online consults’. I think it actually has given people a real kick forward,” he told Digital Health News. “I think in six months’ time my surgery might be very different in that actually we will be doing a lot of online and telephone consults where previously we may have been a bit reluctant." GP practices across the country have been advised to assess patients online or via telephone and video appointments to mitigate the potential spread of coronavirus. In a letter to GPs last week, NHS England urged Britain’s 7,000 GP surgeries to reduce face-to-face appoints for patients displaying symptoms of Covid-19. The preemptive move means millions of patients will now be triaged online, via telephone or video and contacted via text messaging services. Read full story Source: Digital Health News, 13 March 2020
  23. Content Article
    The U.S. Military Health System cares for over 9 million patients and encompasses 63 hospitals and 413 clinics worldwide. Military medicine balances the simultaneous tasks of caring for those patients wounded in military engagements, treating large numbers of families of service men and women, and training the next generation of health care providers and ancillary staff. Similar to civilian health care delivery in the United States, military medicine has also seen increased scrutiny in the areas of cost and quality.  To determine the scope of complication rates, data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) were analysed. The goal of this article from Maturo et al. was to describe the NSQIP surgical outcome data for the U.S. Military's largest medical center from 2009 to 2014 and compare national averages in the areas of mortality, morbidity, cardiac occurrences, pneumonia, unplanned intubation, ventilator use greater than 48 hours, infections, readmissions, and return to operating room. 
  24. Community Post
    Three blogs originally published in the Guardian highlight the serious concerns doctors are having: ‘We don’t have the masks, goggles – or the staff’ "I'm losing faith in the leadership" "There is a policy of surrender"
  25. News Article
    Who is being tested for coronavirus in the UK? As of last week, when the Prime Minister announced Britain was no longer in the “contain” phase of the pandemic, most testing outside of hospitals stopped. People with symptoms are expected to self-isolate but will not know whether they have COVID-19. That means they will not know if they are immune or still at risk – and a risk to other people. Testing now mostly takes place in hospital. People in intensive care units and those with respiratory illness, especially if it is pneumonia, will get tested for COVID-19. When there is a cluster of infections, such as an outbreak in a care home, those people will also be tested. But the World Health Organization has criticised the approach of countries that are not prioritising testing, with its director general saying “you cannot fight a fire blindfolded … test, test, test”. So why are people with symptoms not being tested? It appears to be a capacity issue, although the Department of Health and Social Care failed to respond to repeated requests for explanation. So far there have been about 44,000 tests in England, which the government’s chief scientific adviser, Sir Patrick Vallance, told the health select committee put it in “the top three or four countries in terms of testing”. Read full story Source: BBC News, 17 March 2020
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