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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Administrative data systems are used to identify hospital-based patient safety events; few studies evaluate their accuracy. McIsaac assessed the accuracy of a new set of patient safety indicators (designed to identify in hospital complications).
  2. News Article
    Mike Ramsay has been appointed new Chairman of the Patient Safety Movement Foundation, taking over from Joe Kiani. The Patient Safety Movement's goal is to get to ZERO preventable deaths. In their latest newsletter, Mike discusses how he intends to build on the tremendous momentum gained so far. "We are not competing with any organization but strongly support entities with the patient safety goal and hope that we can all pull together and use all our resources to reach zero preventable deaths and zero harm. Zero is our target and we can get there!" Read Mike's Letter in the March Patient Safety Movement Foundation newsletter
  3. Content Article
    Professor Tim Cook and Dr Kariem El-Boghdadly discuss in this blog the challenges the coronavirus presents to healthcare services. Central to the care of patients with coronavirus is staff safety. In the early stages, patients will need to be isolated from other patients and, as the epidemic progresses, they will need to be cohorted away from non-infected patients. Staff protection will require a system that includes, but is not restricted to, strict use of personal protective equipment (PPE). Use of PPE, using a buddy system to ensure this is optimised and engaging in low patient contact methods will need to become second nature for all healthcare workers. Anaesthetists and intensivists are highly invested in this topic because airway management, including tracheal intubation, is associated with some of the highest risks of transmission of infection. PPE is likely to be effective, so too are simple methods of decontamination of surfaces, equipment and ourselves with soap and alcohol-based cleaning processes.
  4. News Article
    Doctors who look after patients in a vegetative or minimally conscious state must ensure they initiate regular conversations with relatives about what is in the best interests of the person so that they do not get “lost in the system,” says new guidance. The Royal College of Physicians has published new and revised guidelines on prolonged disorders of consciousness (PDOC) to take into account changes in the law and developments in assessment and management. Read full story (paywalled) Source: BMJ, 6 March 2020
  5. Content Article
    The Prolonged disorders of consciousness national clinical guidelines are a major contribution to clinical and ethical standards of care for people with prolonged disorders of consciousness (PDOC) – including vegetative (VS) and minimally conscious states (MCS) – following sudden onset brain injury, not only in the UK but internationally. For England and Wales, they provide much-needed clarity on legal decision-making. The guidelines were developed by the PDOC Guideline Development Group, which included representation of patients/users and a wide range of stakeholders and professionals involved in the management of patients with PDOC. People in a vegetative or minimally conscious state present a complex array of medical, ethical and legal challenges.
  6. News Article
    Regional NHS leaders in England have been ordered to immediately organise a primary care management service to care for covid-19 patients who “do not require immediate admission” to hospital. In a letter sent on 8 March, seen by The BMJ, NHS England and NHS Improvement’s strategic incident director for coronavirus, Keith Willett, has ordered regional primary care and public health directors to set up a 24 hour, seven day a week service to manage patients in the community. This service should be delivered by an out-of-hours provider, and every part of England must be covered by Tuesday 10 March, the letter said. The service will be used to manage patients who are deemed well enough to be isolated at home, with active monitoring for people who are at high risk of developing severe illness, and advice to those not deemed high risk on what to do if their illness deteriorates. The letter advises that patients “remain in isolation until 5 days after resolution of symptoms, unless [they are a] healthcare worker or work with high risk groups, in which case require one negative sample 5 days after resolution of symptoms before return to work.” People with mild illness and not in a high risk group will be told to isolate themselves at home and will be given health advice on how to identify deterioration. All patients managed at home will be given a phone number to call if they feel more unwell. The letter said that the community service should be provided by a nurse and GP team and that all clinical information should be recorded and transferred to the patient’s general practice. Providers must also provide regular situation reports, including confirmed numbers of patients cared for under the service, numbers of patients who deteriorate, and numbers of patients admitted to and discharged from the service. Read full story Source: BMJ, 9 March 2020
  7. News Article
    Sir Norman Lamb, chair of South London and Maudsley Foundation Trust and a former Liberal Democrat MP, has suggested the government would lose a legal challenge over its national programme for patients with learning disabilities and said the national Transforming Care programme was at the “very least a partial failure”. “I regard this as a human rights issue. We’re locking people up when we don’t need to lock them up. We’re subjecting them to force, when we shouldn’t do so, and this is how I think we need to frame it. If the government were challenged in court on this, I think there’s a very good chance, as an ex-lawyer, that they would lose.” Transforming Care was launched in 2011 following the Winterborne View scandal and aimed to discharge patients with learning disabilities and autism out of institutional inpatient units into the community. However, the most recent figures, from NHS Digital, show there were still more than 2,000 patients within inpatient units, ahead of the national programme’s expiration this month. Kevin Cleary, deputy chief inspector for hospitals and lead for learning disability and mental health services for the CQC, said: “We have allowed our patients to be placed within places like Whorlton Hall. I think the NHS provides very few services of this type, it has withdrawn from providing these services, and has become comfortable with providing that service, within the independent sector, several hundred miles away and that’s not right… absolutely not right." “We cannot say we are providing patient centred care or say we are placing the patient at the heart of everything we do and have that response from the system. We are all responsible for that.” Read full story (paywalled) Source: HSJ, 10 March 2020
  8. Content Article
    The WHO guidelines on hand hygiene in health care provide healthcare workers (HCWs), hospital administrators and health authorities with a thorough review of evidence on hand hygiene in health care and specific recommendations to improve practices and reduce transmission of pathogenic microorganisms to patients and HCWs. The present guidelines are intended to be implemented in any situation in which healthcare is delivered either to a patient or to a specific group in a population. Therefore, this concept applies to all settings where healthcare is permanently or occasionally performed.
  9. Content Article
    In this article, Cruikshanks and Bryden outline the process that should take place after an adverse event has occurred.
  10. News Article
    Visitors to a hospital are stealing hand sanitising gel daily – as demand for the product surges amid fears over coronavirus. Bottles have been taken from patients' beds and dispensers ripped off walls at Northampton General Hospital. Bosses said the gel was "disappearing every day" and they have had to limit the supply on wards. "Nothing like this has ever happened in all the years we've had the gel," said a hospital spokeswoman. "Over the past week we've seen stocks on wards disappear from the end of beds every single day," Sally-Anne Watts, associate communications director, told the BBC. "Three wall-mounted dispensers have been ripped off and we've even seen people coming in and topping up their own dispensers with our product," she said. Since the hospital's supplies have been going missing, Mrs Watts said, bottles were no longer being put at the end of all beds. "We don't have an unlimited supply and would ask that visitors to the site respect the fact that we are doing all we can to keep our patients, visitors and staff safe, and we need their support," she added. Read full story Source: BBC News, 6 March 2020
  11. Content Article
    NHS England has provided links to the up-to-date guidance healthcare professionals need to respond to coronavirus (COVID-19). Clinicians and members of the public can check the government’s response to coronavirus and travel advice on gov.uk.
  12. Content Article
    The purpose of this guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) is to urge all maternity units to consider the use of the Maternity Dashboard to plan and improve their maternity services. It serves as a clinical performance and governance score card to monitor the implementation of the principles of clinical governance on the ground. This may help to identify patient safety issues in advance so that timely and appropriate action can be instituted to ensure a woman-centred, high-quality, safe maternity care.
  13. News Article
    This week is Patient Safety Awareness Week, an annual recognition event intended to encourage everyone to learn more about healthcare safety. During this week, the Institute for Healthcare Improvement (IHI) seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce. Patient Safety Awareness Week serves as a dedicated time and platform for growing awareness about patient safety and recognising the work already being done. Although there has been real progress made in patient safety over the past two decades, current estimates cite medical harm as a leading cause of death worldwide. The World Health Organization estimates that 134 million adverse events occur each year due to unsafe care in hospitals in low- and middle-income countries, resulting in some 2.6 million deaths. Additionally, some 40 percent of patients experience harm in ambulatory and primary care settings with an estimated 80 percent of these harms being preventable, according to WHO. Some studies suggest that as many as 400,000 deaths occur in the United States each year as a result of errors or preventable harm. Not every case of harm results in death, yet they can cause long-term impact on the patient's physical health, emotional health, financial well-being, or family relationships. Preventing harm in healthcare settings is a public health concern. Everyone interacts with the health care system at some point in life. And everyone has a role to play in advancing safe healthcare. Learn more about IHI's work to advance patient safety.
  14. Content Article
    Crucial reports and strategic reviews about the quality of maternity care in different parts of the UK have consistently identified that improvements should be underpinned by implementation of existing evidence-based clinical standards. The Royal College of Midwives (RCM) identified that to deliver compassionate, well-led, professional evidence-based midwifery care which maximises midwives’ contributions to improving quality also required midwifery service standards within a framework which could be used by service providers, commissioners and RCM members. A small project team was tasked with developing The RCM Standards for midwifery services in the UK. The team developed the standards using a pragmatic review of the evidence available and through consensus informed by views, comments and suggestions on draft outputs from respondents.
  15. Content Article
    Better Births set out a compelling view of what maternity services should look like in the future. The vision is clear: we should work together across organisational boundaries in larger place-based systems to provide a service that is kind, professional and safe, offering women informed choice and a better experience by personalising their care. Whilst Better Births described the vision, this resource pack sets out in detail what needs to be done and how it can be accomplished across the whole of England. It is designed to provide tools to help Local Maternity Systems turn the vision into reality and the practical advice needed to plan, commission and operate maternity services in their localities.  
  16. Content Article
    Imagine if hospitals could fly? Would they be safer for patients? Before you say to yourself, what a silly question. Please hear me out… Abdulelah M. Alhawsawi is Director General at the Saudi Patient Safety Center.
  17. Content Article
    This document provides technical guidance for government authorities, health workers, and other key stakeholders to guide response to community spread. It will be updated as new information or technical guidance become available. For countries that are already preparing or responding, this document can also serve as a checklist to identify any remaining gaps.
  18. Content Article
    The Parliamentary and Health Service Ombudsman (PHSO) make final decisions on complaints that have not been resolved by the NHS in England, UK government departments and other UK public organisations. The PHSO look into complaints where someone believes there has been injustice or hardship because an organisation has not acted properly or has given a poor service and not put things right. The PHSO looks into complaints fairly, and the service is free for everyone. This first annual Ombudsman’s Casework Report highlights the breadth of cases received across PHSO's jurisdictions. It is only a small cross-section of the cases completed in 2019. The complaints presented here are typical of many of the complaints seen across PHSO's remit. They include complaints about government bodies and the NHS.
  19. Content Article
    The World Health Organization (WHO) have created this poster to give advice on how to cope if you feel worried about the coronavirus.
  20. Content Article
    Family members are a vital part of the healthcare team and are often best positioned to recognize the sometimes subtle, yet very important changes in their loved one's condition that may indicate deterioration. You may not know WHAT is wrong, but you know something just isn't right. Empower yourself and your loved ones with the following information and resources from the Canadian Patient Safety Institute (CPSI). They will both help you recognize the signs of deteriorating patient condition, and effectively discuss your concerns with the healthcare provider.
  21. News Article
    The Royal College of Nursing (RCN) has issued a warning about insufficient staffing in the NHS in the wake of a mental health trust being downgraded. Earlier this week, Tees, Esk and Wear Valleys (TEVW) NHS Foundation Trust being rated as "requiring improvement" by the Care Quality Commission. It had previously been rated as "good" but inspectors said some services had deteriorated. Among the concerns raised were ones over staffing, workload and delays. Glenn Turp, Northern Regional Director of the RCN: "The CQC has rightly highlighted some very serious concerns and failings which call into question whether this trust can provide safe patient care. After the very tragic and sad deaths of two vulnerable patients last year and the findings of the CQC, the trust and NHS commissioners must take immediate action to ensure patient and staff safety." "They have a responsibility not to commission and open new beds with insufficient nursing staff to provide safe patient care. Having the right number of nursing staff with the right skills in the right place at the right time is critical to protecting patients. It also protects those staff who too often find themselves struggling to maintain services in the face of nursing vacancies." Read full story Source: The Northern Echo, 7 March 2020
  22. News Article
    Executives in charge of the health secretary’s crisis-hit local hospital are facing calls to step down after The Sunday Times raised serious questions about attempts to cover up catastrophic medical mistakes. West Suffolk Hospital in Bury St Edmunds had placed Dr Patricia Mills, one of its most senior consultants, under disciplinary investigation after she had voiced concerns about blunders that had killed one patient and left another seriously brain-damaged. A number of doctors have claimed that a bullying management culture has led to staff being too afraid to speak up about patient safety concerns at the hospital. Executives were accused of being obsessed with maintaining the hospital’s “outstanding” status in annual Care Quality Commission. One of the governors said their were "frustrations and concerns" among his fellow council members that they were being kept in the dark by the hospital's executives. Read full story (paywalled) Source: The Sunday Times, 8 March 2020
  23. Content Article
    The Intensive Care Society has created a page to provide the critical care community with resources and information on COVID-19. The Society is collaborating with Government, FICM and other agencies to ensure they provide consistent, up to date and relevant messaging to support your understanding of and management of COVID-19.
  24. Content Article
    Advice from the World Health Organization.
  25. Content Article
    Washing your hands is one of the easiest ways to protect yourself and others from illnesses. The NHS has provided a short video to find out the best way to wash your hands and top tips.
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