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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Resource booklet for NHSScotland board members with an interest in improvement governance.
  2. Content Article
    This international review from the Health Information and Quality Authority highlights the considerable variation in place across countries in relation to patient safety reporting. It is clear however, that the coordination and triangulation of patient safety intelligence for risk profiling is extremely important. Incidents need to be combined with other quality and patient safety sources of information.
  3. News Article
    Channel 4 News says they have seen a Public Health England document indicating that not all healthcare and other essential workers with symptoms will be tested because there simply isn’t the capacity to do so – with testing prioritised in order of clinical need. Public Health England say they won’t comment on the contents of a leaked document and it is still subject to ongoing discussions. View full story Source: Channel 4 News, 15 March 2020
  4. Content Article
    Do you know your medicines? Do you keep a list? Can you describe and discuss your medicines with healthcare professionals and family when you want to? Ireland's Health Service Executive's National Medication Safety Programme works with patients to improve the safe use of medicines.
  5. Content Article
    Patients and service users ask us to be clear when we give them information about their health. They also want us to show care and compassion when we talk and write to them. When we explain things clearly and with care and compassion, people have more confidence and trust in us and are more likely to take our advice, and follow medical guidance. They are happy to ask us questions about our advice so that they can take better care of their health. The Health Service Executive gives tips on how we can communicate clearly with patients and service users.
  6. Content Article
    The Republic of Ireland's Health Service Executive Patient Safety Strategy makes six commitments: Empower and engage patients to improve patient safety. Empower staff to improve patient safety. Anticipate and respond to risks to patient safety. Reduce common causes of harm. Measure and learn to improve patient safety. Provide effective leadership and governance to improve patient safety.
  7. News Article
    The Care Quality Commission (CQC) has suspended its routine inspections due to the coronavirus outbreak following pressure from system leaders and NHS bosses. The decision to suspend inspections where there are no immediate safety concerns is understood to have been taken by the CQC’s executive team this morning, senior sources told HSJ. Both the NHS Confederation and The Royal College of GPs said the decision had been made. NHS Confederation called the move a “sigh of relief” for front-line staff, while the RCGPs said it would enable GPs to dedicate their time to providing care. NHS Confederation chief executive Niall Dickson said: “Front-line staff will breathe a sigh of relief that CQC has responded to our concerns and will now postpone its inspections where there is no immediate safety concern so that they can gear themselves up to prepare for the huge task ahead in dealing with the coronavirus pandemic.” Read full story Source: HSJ, 16 March 2020
  8. Content Article
    The Perioperative Warming Quality Improvement Resource summarises the evidence for temperature monitoring, pre, intra and post-operative warming, plus intravenous and irrigation fluids. See also the Perioperative Warming Decision Guide to help support what pre, intra and post-op actions need to be taken to prevent inadvertant perioperative hypothermia.
  9. Content Article
    The aim of this article is to enable nurses to understand the powerful role of organisational culture in influencing the effectiveness of healthcare delivery, primarily within the NHS.
  10. Content Article
    The Surgical Skin Preparation Quality Improvement Resource summarises the evidence for patient washing, hair removal, skin disinfection and the use of incise drapes.
  11. Content Article
    Learn about the latest scientific evidence around theatre ventilation, movement in and out of theatres and the cleaning processes.
  12. Content Article
    A guide about skin preparation and disinfection to help reduce the risk of surgical site infection.
  13. Content Article
    The OneTogether Quality Improvement Resources are intended to provide practical information for implementing best practice for each of the elements of care across the surgical pathway. These resources can be used as stand‑alone documents, but are recommended to be used in conjunction with the OneTogether Assessment Toolkit. The OneTogether Assessment Toolkit is designed to measure adherence to best practice to prevent surgical site infection (SSI). Following completion of the OneTogether Assessment, healthcare professionals will be able to identify areas of low compliance and develop a prioritised action plan for improvement. The Quality Improvement Resources summarise the evidence underpinning recommended practice and provide a competency assessment checklist. The information they contain is drawn from evidence-based guidelines or expert recommendations from professional bodies
  14. Content Article
    Educate and inspire your surgical teams to adopt the recommended guidance across the surgical pathway.
  15. Content Article
    “Just culture” is rightly, a much-used phrase in patient safety and a major theme in the patient safety strategy for England and all the UK countries. However, there is no single definition of ‘just culture’ and most discussion of it is limited to the issue of being fair to healthcare staff. This is vitally important, which is why we advised on and endorsed the NHS Resolution Being Fair guidance and NHS Improvement’s Just Culture Guide. However, AvMA and many of the stakeholders believe that we need a nationally agreed definition that places equal emphasis on being fair to patients and families, and which covers the whole system, from policy formulation to the delivery of healthcare and what happens when harm occurs.
  16. Content Article
    "ALARP" is short for "as low as reasonably practicable". "SFAIRP" is short for "so far as is reasonably practicable". The two terms mean essentially the same thing and at their core is the concept of "reasonably practicable"; this involves weighing a risk against the trouble, time and money needed to control it. Thus, ALARP describes the level to which we expect to see workplace risks controlled. This guide from the Health and Safety Executive has been produced to explain the concept of "reasonably practicable" in a simple way for those new to decision making and incorporates guidance currently held on HSE's website.
  17. Content Article
    The Health and Safety Executive describes why organisation culture is important and the key principles on organisational culture. They also provide links to further guidance on organisation culture.
  18. Content Article
    The Global Tracheostomy Collaborative has created a community where a multidisciplinary team of healthcare professionals, patients and families are empowered to learn and continuously improve the outcomes of patients with tracheostomies.
  19. Content Article
    This group is designed to bring together mothers (and fathers) of children (of all ages) with a tracheostomy, for support and advice. It is a group for parents only.
  20. Content Article
    The goal of the UK National Tracheostomy Project is to improve the safety and quality of care for patients with tracheostomies and laryngectomies through education. The project has collaborated with key stakeholders in tracheostomy care to develop freely accessible resources, supported by online learning developed with the Department of Health.
  21. Content Article
    Coronavirus has plunged the world into uncertainty and the constant news about the pandemic can feel relentless. All of this is taking its toll on people's mental health, particularly those already living with conditions like anxiety and OCD. So how can we protect our mental health? This BBC article gives some useful advice.
  22. Content Article
    The rapid spread of COVID-19, and the fact that healthcare facilities could be sources of contagion, has focused attention on new models of care that avoid face-to-face contact between clinician and patient. There has been particular interest in video consultations, which are already being rolled out in many countries as part of national digital health strategies. In this Editorial in the BMJ, Trisha Greenhalgh and colleagues discuss how appropriate video consultations are for dealing with the coronavirus crisis and what are the challenges of scaling up this model at speed.
  23. News Article
    Matt Morgan, an intensive care doctor, describes in this Guardian article how his ICU are preparing for the coronavirus crisis. "ICUs are as prepared as they can be. Locally business as usual has made way for preparations for caring for high numbers of patients. We are finding every ventilator we may have and identifying every suitably qualified member of staff. We will work together to fill gaps as best we can. There’s a sense of anticipation about what the next eight, 10, 12 weeks are going to bring in terms of work. Anyone who works in healthcare is also a mum, dad, daughter, brother, son. We want to give everything to saving lives and work and care, but equally we’re thinking about the logistics of personal lives and elderly relatives too." Matt says his worst nightmare is having insufficient workforce and equipment to meet patient needs. Whether or not that will come to fruition is tough to predict. He also says that his ICU has a psychologist who’s doing a huge amount of thinking about putting in place wellbeing resources for staff who might be in moral distress after having to prioritise one patient over another. "If there are 500 patients and only 200 ventilators then that’s when we need national guidance from the government and other bodies. It can’t be up to individual doctors. The age of playing God is long behind us. The question is who should we be making decisions with: the public, government or within the profession?" Read full story Source: The Guardian, 13 March 2020
  24. News Article
    At least 20 maternity deaths or serious harm cases have been linked to a Devon hospital since 2008, according to NHS reports obtained by the BBC. A 2017 review which was never released raised "serious questions" about maternity care at North Devon District Hospital. The BBC spent two years trying to obtain the report and won access to it at a tribunal earlier this year. Northern Devon Healthcare NHS Trust (NDHT) said the unit was "completely different" after recommended reforms. A 2013 review by the Royal College of Obstetricians and Gynaecologists (RCOG) investigated 11 serious clinical incidents at the unit, dating back as far as 2008. The report identified failings in the working relationships at the unit, finding some midwives were working autonomously and some senior doctors failed to give guidance to junior colleagues. Despite the identified problems with "morale", the subsequent investigation by RCOG in 2017 expressed concerns with the "decision-making and clinical competency" of senior doctors and their co-operation with midwives. An independent review into midwifery in October 2017 noted "poor communication" between medical staff on the ward for more than a decade. The report identified a "lack of trust and respect" between staff and "anxiety" among senior midwives at the quality of care. Read full story Source: BBC News, 16 March 2020
  25. News Article
    As coronavirus spreads widely across the UK, many of those who fall sick may seek treatment at their GP's surgery. But are family doctors ready to deal with a wave of patients, prevent the spread of the disease and protect the most vulnerable? "This is a massive crisis, probably the biggest crisis the NHS has ever had to face," says Prof Martin Marshall, an east London GP who is also chair of the Royal College of General Practitioners' council. He says not enough has been done yet to prepare family doctors for the epidemic, although he adds: "We need to be a little bit understanding of the pressures that the whole system is under." As the virus circulates in the community, he says we need "urgent action" to protect healthcare workers, give them the information they need and provide technology to allow for more consultations by phone or the internet. Given the pressures the NHS will be under, Prof Marshall says it is vital that doctors and nurses are not taken out of action for seven days of isolation unnecessarily. "We're not saying that health professionals are more important than patients, we're saying that health professionals have a responsibility," he says. "We therefore need to keep them as healthy as possible and we need to get them back into the workforce as quickly as possible. So we're asking that health professionals are tested early." Read full story Source: BBC News, 16 March 2020
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