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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Advice from the World Health Organization (WHO) on hand hygiene for healthcare workers.
  2. Content Article
    Advice from the World Health Organization (WHO) on protecting yourself against the coronavirus.
  3. Content Article
    A&E is often seen as a service in crisis and is the focus of much media and political interest. But A&E is just the tip of the iceberg -- the whole urgent and emergency care system is complex, and surrounded by myth and confusion. This animation from The King's Fund gives a whistle-stop tour of how the system fits together and busts some myths about what's really going on -- explaining that the underlying causes go much deeper than just A&E and demand a joined-up response across all services.
  4. Content Article
    Helen is a Consultant Anaesthetist at the Oxford University Hospitals NHS Foundation Trust (OUHFT) and a Senior Clinical Research Fellow in the Nuffield Department of Clinical Neurosciences, University of Oxford. Here, Helen highlights the importance of support and training and gives an example of how the OxSTaR team are transforming staff teamworking skills and improving patient safety.
  5. Content Article
    Joanna is a Partner in the law firm Bevan Brittan LLP. In our interview, Joanna talks about her role supporting healthcare staff through the legal and investigatory processes that follow an adverse event, and why we must do all we can to maximise the opportunity to learn when things go wrong in healthcare.
  6. Event
    The Community Hospital Association and the University of Birmingham are holding a conference to share the new evidence on community hospitals from three research studies. This is important new evidence on aspects such as “value,” “efficiency” and “international learning.” Speakers from the research teams from the Universities of Birmingham, Leeds and Bournemouth/RAND will present their findings, and we will be discussing the impact and implications of these. Keynote speaker: Matt Hanncock, Secretary of State for Health and Care. Book tickets
  7. Content Article
    Claire, a Critical Care Outreach Sister, Darzi Fellow and Associate Director for Patient Safety Learning, talks about her passion to make a difference in patient safety and how her two very different roles come together to achieve this ambition.
  8. Content Article
    The Bulletin of the World Health Organization is a fully open-access monthly journal of public health with a special focus on low and middle-income countries.
  9. Content Article
    All patients with prosthetic mechanical heart valves require life-long oral anticoagulation with a vitamin K antagonist (VKA), usually warfarin, as these valves predispose the patient to systemic embolism. Thrombosis of a prosthetic valve is potentially life-threatening as it can result in haemodynamically severe stenosis or regurgitation and acute heart failure. The risk depends on the type of valve, its position, and other factors.  Since 1 March 2020, 14 incidents have been reported of patients with a mechanical heart valve being switched to a a low molecular weight heparin (LMWH) or a direct oral anticoagulant (DOAC); two patients were hospitalised due to valve thrombosis and/or required emergency surgery and one was admitted due to severe anaemia. The reports included cases where patients’ anticoagulation was switched from warfarin in primary and in secondary care.
  10. Content Article
    Dysphagia (swallowing problems) occurs in all care settings and although the true incidence and prevalence are unknown, it is estimated the condition can occur in up to 30% of people aged over 65 years of age. Stroke, neurodegenerative diseases and learning disabilities can be the cause of some cases of dysphagia, and may also result in cognitive or intellectual impairment, as well as visual impairment, NHS England received details of an incident where a care home resident died following the accidental ingestion of the thickening powder that had been left within their reach. Whilst it is important that products remain accessible, all relevant staff need to be aware of potential risks to patient safety. Appropriate storage and administration of thickening powder needs to be embedded within the wider context of protocols, bedside documentation, training programmes and access to expert advice required to safely manage all aspects of the care of individuals with dysphagia. Individualised risk assessment and care planning is required to ensure that vulnerable people are identified and protected.
  11. Content Article Comment
    @Gary Saunders Any thoughts? Scan4Safety is an initiative led by DHSC - @Richard Price I believe the University Hospitals Plymouth NHS Trust is using this?
  12. Event
    Returning to work after a career break or going back to work after an extended period away from work (i.e. maternity leave, research) can prove to be quite a challenge. Whatever the reason, the period of time absent from work can cause a feeling of reduced confidence and a lack of certainty about your ability to perform particular jobs when you return to work. The GASagain course from the Royal College of Anaesthetists is structured to provide you with the strategies for managing a return to work. There will be simulation scenarios to refresh your skills plus a series of workshops, underpinned by short relevant lectures, to update you on the latest in the world of anaesthesia. We will individualise the scenarios to cater to the grade of the anaesthetist. Find out more
  13. Content Article
    Strengthening a safety culture necessitates interventions that simultaneously enable, enact and elaborate in a way that is attuned to the existing culture. Through a literature review of more than 60 resources, a Patient Safety Culture Bundle has been created and validated through interviews with Canadian thought leaders. The Bundle is based on a set of evidence-based practices that must all be applied in order to deliver good care. All components are required to improve the patient safety culture. The Patient Safety Culture "Bundle" for CEOs and Senior Leaders encompasses key concepts of safety science, implementation science, just culture, psychological safety, staff safety/health, patient and family engagement, disruptive behavior, high reliability/resilience, patient safety measurement, frontline leadership, physician leadership, staff engagement, teamwork/communication, and industry-wide standardisation/alignment.
  14. Event
    until
    In its 6th year, this FREE event at the Royal London Hospital is for senior healthcare professionals with an active interest in Perioperative Safety, Quality Improvement and Clinical Governance. The full programme is yet to be finalised but will include sessions on: Innovation (Mark Blunt, King's Lynn) Learning from deaths (Helen Hogan, London School of Hygiene and Tropical Medicine) Informatics (Dan Melley, Barts Health) Consent (John Barcroft, Royal National Orthopaedic Hospital) Learning from legal cases (David Bogod, Nottingham) The day will feature talks and seminars led by leading clinicians and national organisations, networking opportunities and a safety project competition. Further information
  15. News Article
    More than 20 leading NHS doctors and experts back Baby Lifeline demand for safety training for maternity staff to cut £7m a day negligence costs The Independent’s maternity safety campaign goes to Downing Street today as senior figures from across the health service deliver a letter demanding action from prime minister Boris Johnson. Charity Baby Lifeline will be joined by bereaved families, Royal Colleges and senior midwives and doctors in Downing Street to hand in a letter calling on the government to reinstate a national fund for maternity safety training. Baby Lifeline, which has also launched an online petition today, said the government needed to find £19m to support training of both midwives and doctors to prevent deaths and brain damage, which can cost the NHS millions of pounds for a single case. The letter to Mr Johnson has also been signed by Dr Bill Kirkup, who led the investigation into baby deaths at the Morecambe Bay NHS trust and is investigating poor care at the East Kent Hospitals University Trust. He said: “There have been real improvements in maternity services, but as recent events in Kent and Shropshire have shown only too clearly, much more remains to be done. The Maternity Safety Training Fund is badly needed.” Sir Robert Francis QC, Chairman of the public inquiry into poor care at Stafford Hospital, who also signed, said: “The cost in lost and broken lives, not to mention the unsustainable financial burden and the distress of staff caused by these avoidable mistakes, is indefensible.” Other signatories included former health secretary Jeremy Hunt, the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists and a number of senior maternity figures, charities and clinical associations. Read full story Source: The Independent, 6 March 2020
  16. News Article
    Just 1 in 4 UK GPs are satisfied with time they are able to spend with patients – appointment times are among the shortest of 11 countries surveyed. A report published today by the Health Foundation paints a picture of high stress and low satisfaction with workload among UK GPs. The report is an analysis of an international survey of GPs from 11 high-income countries, including 1,001 UK GPs, undertaken by the Commonwealth Fund in 2019. Among 11 high-income countries included in the study, only France has lower levels of overall satisfaction with practising medicine, and only Sweden reported higher levels of stress. Over half of UK GPs (60%) say they find their job 'extremely' or 'very' stressful, and almost half (49%) plan to reduce their weekly hours in the next three years. UK GPs also reported significantly shorter appointment lengths than their international colleagues. The average length of a GP appointment in the UK is 11 minutes, compared with a 19 minute average appointment for GP and primary care physicians in the other countries surveyed. Dr Rebecca Fisher, one of the Health Foundation report's authors and a practising GP, says: "These findings illustrate the pressures faced by general practice, and the strain that GPs are under. Right now the health system is in unprecedented territory and mobilising to meet the challenge of Covid-19. This survey shows that over the long term we need concerted action to stabilise general practice. Despite performing strongly in some aspects of care, many GPs consider that appointments are simply too short to fully meet the needs of patients. Too many GPs are highly stressed and overburdened – to the point of wanting to leave the profession altogether." Read full story Source: The Health Foundation, 5 March 2020
  17. News Article
    An NHS trust at the centre of an inquiry into preventable baby deaths will repay money it received for providing good maternity care. In 2018, Shrewsbury and Telford NHS Trust received almost £1m, weeks before its services were rated inadequate. The BBC revealed in December the trust had qualified for the payment under the NHS's Maternity Incentive Scheme. The trust said an "incorrect submission" had been made and it had ordered an independent review. Shrewsbury and Telford NHS Trust (SaTH) is at the centre of England's largest inquiry into poor maternity care, with more than 900 families contacting a review looking into concerns over preventable deaths and long-term harm. Former health secretary Jeremy Hunt wrote to ministers questioning if improvements to the Maternity Incentive Scheme were needed in light of payments made to both Shrewsbury and Telford and East Kent Hospitals, despite both facing serious questions over the safety of maternity services. The trust in Shropshire was paid £963,391 after certifying it had met the 10 safety standards demanded by the scheme, which is run by NHS Resolution. In the letter, seen by the BBC, Mr Hunt suggested one improvement would be to link payments to CQC maternity and safety ratings. "The whole approach is likely to be discredited if trusts can meet all 10 actions and yet still be delivering poor standards of care," the letter said. Read full story Source: BBC News, 6 March 2020
  18. Content Article
    More than 30 years have passed since the near-fatal medication error but Michael Villeneuve, CEO Canadian Nursing Association, recalls the moment with absolute clarity.
  19. Content Article
    The human element can give us kindness and compassion; it can also give us what we don't want— mistakes and failure. Leilani Schweitzer's son died after a series of medical mistakes. In her talk she discusses the importance and possibilities of transparency in medicine, especially after preventable errors. And how truth and compassion are essential for healing.
  20. Content Article
    Author Hugh MacLeod host's this fourth episode in the ISQua Podcast series. "We do not make stuff in healthcare, we deliver care to people through people. When the relationship patterns between people are connected and healthy quality and patient safety magic happens, when they are not connected nor healthy, things fall through the cracks and patient harm and death occurs."
  21. Content Article
    Change is at the heart of quality improvement in healthcare. As the needs of populations continually fluctuate, healthcare must evolve to reflect and serve those needs. The overarching theme of the 2018 ISQua conference, hosted in Kuala Lumpur, was ‘Heads, hearts and hands weaving the fabric of quality and safety’, which led many speakers to examine change in quality and safety improvement through the lens of these three central elements. Collectively, the conference presentations formed a picture of the global landscape of quality and safety in healthcare and offered many valuable examples of innovation that can facilitate sustainable change. Identifying areas for transformation and implementing change can be relatively straightforward, but lasting change is much more challenging to realise. This topic was widely discussed, with many speakers sharing their experiences and learning on embedding lasting change through organisational culture. It is evident that investing time and resources to engage those on the frontline of healthcare delivery can have a huge impact on quality improvement. 
  22. Content Article
    Health systems throughout the world are now more focused on creating a more patient-centred approach to healthcare, ensuring the voice of the patient is heard through every level of the system. This focus on the patient is driven by a desire to improve quality of care as the two are inevitably linked.  However, some countries are struggling to change systems which take a traditional approach based on a patient’s clinical presentation of signs and symptoms, followed with a management plan and medical treatment.  This report highlights many ways in which we can give patients more say in the decisions about their treatment and care. It draws on keynote presentations and seminars from ISQua 2017 – a world-leading conference on quality improvement. 
  23. Content Article
    As we look to the future, the healthcare industry is at a critical juncture. The rapid development of theories on how to deliver safe, person-centred care means that we can no longer rely on the excuse that “healthcare is different” from other industries and cannot be reliable and safe. People are now demanding safety and reliability in the care they receive, and they want to be treated as people who happen to be ill rather than as a number or a disease. Currently, it is by chance rather than by design that one receives highly reliable person-centred and safe care. Yet we continue to build the same type of hospitals, educate future nurses and clinicians as we have always done and operate in a hierarchical system that disempowers people, rather than enables people to be healthy. Although the provision of healthcare is complex, it is possible to overcome the complexity and provide care that is of the highest standard in all the domains of quality.  To achieve this, Peter Lachman in his blog suggests six steps to be considered.
  24. Content Article
    This one-hour webinar considers the redesign of the patients journey and experience. Using theories that rethink the relationship between provider and ‘customer or client’, it explores co-producing better care relevant to any speciality, environment or healthcare system. This will include some practical examples learners can adapt to their own situation. By the end of the session learners will be familiar with a framework that can enable teams to work with patients to build safer, more effective and efficient care that is focused on what matters to patients and families as well as excellent performance from the team.
  25. News Article
    Women are at risk of serious harm and death because hospitals are not always diagnosing ectopic pregnancies quickly enough, an investigation reveals. About 12,000 women a year in the UK suffer an ectopic pregnancy – when a fertilised egg grows outside the womb – putting them at risk if a fallopian tube containing the foetus ruptures and causes potentially fatal heavy bleeding. An investigation by the Healthcare Safety Investigation Branch (HSIB) has found flaws in the treatment women receive. It has highlighted late diagnosis and consequent delay in treatment as a major concern, especially as a result of the condition being mistaken for a urinary tract infection. NHS patient safety data shows that 30 ectopic pregnancies were missed and led to “serious harm” between April 2017 and August 2018. As well as the risk to life, an ectopic pregnancy can also damage a woman’s chances of conceiving again and have serious psychological effects. Read full story Source: The Guardian, 5 March 2020
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