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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This resource from the National Institute for Health and Care Excellence includes assessment tools that can be used to evaluate current practice and plan activity to meet recommendations, audit tools which can be used to improve care, a quality standard service improvement template (Excel), resource impact reports and templates that summarise the resource impact of implementing NICE guidance and service planning tools to help those with a role in the strategic planning or delivery of services for a condition (or set of circumstances) that are addressed by NICE guidance.
  2. Content Article
    This document by the National Institute for Clinical Excellence sets out the principles for best practice in clinical audit and includes; preparing for audit, selecting criteria, measuring level of performance, making improvements and sustaining improvement.
  3. Content Article
    This patient-centred report from the Regulatory Horizons Council discusses a route to more effective safety assurance through mechanisms that consider the whole product lifecycle, how adverse events are detected or a long time after use of the device and how to trace and recall patients when needed. In addition, this report also considers a number of ways in which use of data and technology can be smarter and to join up digital systems.
  4. News Article
    Nottingham University Hospitals Trust has been served with a section 29a warning notice by the Care Quality Commission requiring it to ensure a ‘more positive culture’. A CQC spokeswoman confirmed: “The trust was issued with a warning notice requiring it to take action to improve corporate and clinical governance and oversight of risk, and to ensure a more positive, open and supportive culture across the organisation. We will report on the full findings from the inspection as soon as we are able to.” Although it is still not clear why the warning was issued, the trust is currently engaged in concerns over their accident and emergency department and maternity services. “We accept the CQC’s comments and work is already underway to learn from the findings and make improvements so that the organisation is led as effectively as possible and we continue to provide world class care for our patients.” Nottingham University Hospitals Trust acting chief executive and chief finance officer Rupert Egginton has said. Read full story (paywalled). Source: HSJ, 18 August 2021
  5. News Article
    Ashford and St Peter’s Hospitals Foundation Trust, has apologised after nearly 1,000 patients faced delays due to a breakdown of referral systems. It was found 175 of these patients were considered urgent cases by their GPs and are now being reviewed for clinical harm. When the error was discovered, the patients were added to the referral tacker by 9 July, however until that point, they had not been on any patient waiting list, nor were they visible to either operational management or clinical teams. Trust chief executive Suzanne Rankin said in a statement: “We are very sorry for any inconvenience these delays may have caused patients and we contacted all concerned and issued appointments where necessary.” Read full story (paywalled). Source: HSJ, 19 August 2021
  6. News Article
    Fifty senior consultants from a minority ethnic background at University Hospitals North Midlands have written to Tracy Bullock and trust chair David Wakefield asking for action to ‘protect’ staff from bullying behaviours following an internal survey in which 348 medics claimed to have experienced bullying and harassment. In a subsequent letter on 5 August, seen by HSJ, 50 doctors have now said: “We are forced to express our concerns over the prevailing poor culture within our organisation with most senior medical staff presently reporting they have suffered or witnessed first-hand discrimination, bullying, harassment, or victimisation. We… ask for urgent action by the executive and non-executive boards to immediately implement measures to protect senior medical staff from unacceptable ill-treatment.” A separate external review is now understood to have been commissioned amid concerns over bullying within ophthalmology services. Read full story (paywalled). Source: HSJ, 19 August 2021
  7. News Article
    According to new data, those who have been vaccinated against Covid-19, can still harbour virus levels as high as unvaccinated people if infected with the Delta variant. This new data suggests that hitting the threshold for herd immunity remains unlikely. However, it evidence does show vaccination still offers protection against hospitals and infection. “We don’t yet know how much transmission can happen from people who get Covid-19 after being vaccinated – for example, they may have high levels of virus for shorter periods of time, but the fact that they can have high levels of virus suggests that people who aren’t yet vaccinated may not be as protected from the Delta variant as we hoped.” said Sarah Walker, a professor of medical statistics and epidemiology at the University of Oxford. Read full story. Source: The Guardian, 19 August 2021
  8. News Article
    In a positive step towards the future of pathology, NHS Digital has received approval from the Data Alliance Partnership Board (DAPB) for a new set of pathology information standards, and as part of NHS England CCIO7 workstreams, NHS Digital are delivering the ability to share pathology results across health and care. This move will enable clinicians to share and access critical information about pathology tests and results and receive the right information when they need it, which will help support improved clinical decision making and patient safety. Read full story. Source: Wired Gov, 19 August 2021
  9. News Article
    According to recent reports, the number of patients on waiting lists for non-urgent hospital treatment in Wales has again hit record levels. Data has revealed there were 624,909 people waiting in June, and those waiting the longest, more than nine months, rose again to 233,210. A Welsh government spokesperson said: "Waiting times for treatment continue to grow. However, it is encouraging to see progress being made with the number of patients waiting over 52 weeks falling for the third month in a row. We also saw the largest number of specialist consultations completed and treatments started in any month since the start of the pandemic." A&E time performance has been at its worst on record, with 94,176 attendances to emergency units over the month. Health spokesman Russell George said: "To record the worst ever A&E waiting times and the longest NHS treatment waiting list in the same month shows a complete lack of leadership." Read full story. Source: BBC News, 19 August 2021 Related Reading Patient Safety Learning blog: Tackling the care and treatment backlog safely (19 August 2021)
  10. Content Article
    Many surgeons prefer to perform total knee replacement surgery with the aid of a tourniquet. A tourniquet is an occlusive device that restricts distal blood flow to help create a bloodless field during the procedure. This article considers the results of a review that compared knee replacement with use of a tourniquet versus without use of a tourniquet and non‐randomised studies with more than 1000 participants. It highlights the risks of complications such as blood clots and infections associated with this, and indicates that changing surgical practice to avoid using tourniquets could avoid nearly 2,000 serious complications in the UK each year.
  11. Content Article
    This is the first of two blogs by Patient Safety Learning looking at the key patient safety issues faced by the healthcare system in the UK in tackling the care and treatment backlog created by the Covid-19 pandemic. This blog outlines the scale of the challenge and sets out the key patient safety considerations associated with this. It stresses the need for national and local plans to address the backlog, with an emphasis on patient engagement and placing patient safety at their core.
  12. Content Article
    This issue of the National Health Executive magazine features a wide range of timely health topics, including; improving employee mental health and ambulance services, prioritising staff wellbeing, equitable access to Covid-19 vaccines, military style mental health support and more.
  13. Content Article
    This webpage contains information about local and national clinical audits including: The National Clinical Audit and Patient Outcomes Programme (NCAPOP) National Quality Improvement and Clinical Audit Network (NQICAN).
  14. News Article
    Selena Brash, a clinical team lead with the East Hampshire school nursing team, has spoken out about the controversial plans to cut back public health nursing services in Hampshire. Ms Brash, in response to the Hampshire County Council plans to save £6.8m from its public health budget, started a petition earlier in the summer calling for increased funding “to protect the provision of school nurses”, warning that cuts to to public health school nursing services would “result in a detrimental effect on children and young people’s health and wellbeing, with lifelong consequences”. “If the cuts go ahead, then this could set a precedent for other local authorities to follow suit, meaning there would be a massive impact on the health and wellbeing of our young people and future generations,” Ms Brash told Nursing Times. Read full story. Source: Nursing Times
  15. News Article
    According to public health reports, there has been a sharp rise in drug overdoses, particularly heroin, over the past 10-14 days with the synthetic opioid isotonitazene implicated in some cases. In several areas of the country including five London boroughs, Hampshire, Essex, West Sussex, Dorset and Thames Valley, there has been 46 poisonings, resulting in 16 deaths, although currently, investigations are still ongoing. In a National Patient Safety alert issued on 18 August 2021, Public Health England (PHE) have instructed all NHS organisations to ensure staff are made aware of the risk of severe toxicity resulting from the synthetic opioid, and that all organisations that treat emergency cases should ensure staff are able to treat suspected cases “using naloxone and appropriate supportive care”. Roz Gittins, director of pharmacy at the charity Humankind, said "People also need to know where they can get hold of naloxone, as well as being reminded to carry it with them and to let people know where they keep it. If advice and support is required then the local substance misuse service should be contacted for specialist support. We hope that the current consultation to widen naloxone provision will be successful and that improved funding will lead to naloxone being distributed more widely to help reduce the risk of accidental opioid overdoses." Read full story. Source: The Pharmaceutical Journal, 18 August 2021
  16. News Article
    After three Covid-19 patients died at the make-shift Nightingale Hospital in London following a breathing tube mix-up, NHS trusts in England could be issued tougher ventilation guidance. In each of the cases, filters which prevent the build-up of fluid were not attached to the machines, resulting in dangerous blockages, but it has not yet been determined if these incidents contributed to their deaths. Coroner Nadia Persaud has said the way the machines vary from model to model can be "confusing" and may lead to future deaths, also ruling that the classification and colour coding was "worthy of review, simplification, and standardisation". The original coroners report, carrying advice from an independent expert said "In my opinion, the non-standardised colour coding used by manufacturers of these filters, the number of different types of filters with different names, the variable optimal position of the filters, and whether a wet or a dry breathing system is being used, results in an extremely confusing situation. One of the leading manufacturers of these filters produces HMEs that are blue, which is the same colour as the non-HME filters supplied by another company. In my experience, few doctors and nurses working in ICU are knowledgeable about all these different filters and which ones should be used for any given breathing system." Inquests into the deaths are scheduled for October. Read full story. Source: The Daily Mail, 17 August 2021
  17. News Article
    According to reports, the number of children being treated by the NHS has soared, with waiting times tripling in a year, and experts warning the pandemic may have set back treatment for young people "by years". The Royal College of Psychiatrists have also said services are struggling to provide timely treatment due to an "overwhelming" demand. Dr Agnes Ayton, the chair of the Royal College of Psychiatrists Faculty of Eating Disorders Psychiatry, said: “The pandemic has had a huge impact on children and young people with disruption to their schooling, social lives and home lives. Many young people have not received support early enough, causing their eating disorders to become much worse and harder to treat. Delays to treatment can put lives at risk. Services are struggling with soaring demand, fewer beds because of social distancing and an ongoing shortage of specialist doctors.” Read full story. Source: The Independent, 19 August 2021
  18. Content Article
    This article discusses the prevalence and cost of hospital-acquired conditions (HACs) and patient safety events (PSIs) associated with procedures that may below value, and reports on the prevalence of adverse events associated with potential low-value procedures and the additional hospital length of stay (LOS) and costs. 
  19. Content Article
    This article examines the challenges in regulating patient safety during hospital discharges in England through the lens of liminality. In addition, this article proposes that by positioning the new role of Patient Safety Commissioner (PSC) as that of a ‘Representative of Order’, it could be a means by which this poorly regulated space could be navigated more successfully.
  20. Content Article
    This article by Tanya Albert Henry discusses poor “cognitive ergonomics” and how the American Medical Association has studied burnout among doctors and is currently addressing issues causing and fuelling physician burnout—including time constraints, technology and regulations—to better understand and reduce the challenges physicians face. 
  21. News Article
    This interview with April Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, a critical care nurse, discusses how Nurse Practitioners are changing healthcare, the likelihood of all states granting full practice authority to NPs, and what the American Association of Nurse Practitioner members can expect from her for the next two years. Read full story. Source: American Medical Association, 16 August 2021
  22. News Article
    Vaccinated nurses will now be expected to return to work instead of isolating as new rules are set to relax. In a letter on the latest rule change from NHS England chief nursing officer Ruth May, chief people officer Prerana Issar, and medical director for primary care Dr Nikita Kanani said “Fully vaccinated staff and students who are identified as a contact of a positive Covid-19 case will no longer be expected to isolate and will be expected to return to work.” Staff returning to work are required to have been double jabbed, have no Covid-19 symptoms and receive a negative PCR test. This latest change in rules go in line with changes for the wider population. Read full story. Source: Nursing Times, 16 August 2021
  23. News Article
    With just hours left to go, a health watchdog has paused a final update to ME treatment guidance due to disagreement on some of it's contents. Charities have expressed their anger over this decision as NICE says it needs more discussions with patient groups and professionals so that the advice is supported. Although it is not yet clear when the guidance will be published, the advice on CBT (cognitive behavioural therapy) has been changed as it was only helping with anxiety around the condition rather than the illness itself, with NICE acknowledging the controversy over the best treatment has served only to alienate many people with the condition. "We were extremely concerned that the final guidelines proposed by NICE may not have taken into consideration the extensive comments we made to the draft version, particularly in relation to treatments we know to have significantly benefited many patients." Andrew Goddard, president of the Royal College of Physicians, has said. Read full story. Source: BBC News, 17 August 2021
  24. Content Article
    This article describes what to be expect when coming off of antidepressants, withdrawal problems, the importance of safely tapering off medication and the need for extreme care and support for patients coming off prescribed antidepressants and benzodiazepines.
  25. Content Article
    This research focused on the Clinical pharmacist (CP) interventions from the PROTECTED-UK cohort. Data was collected from 21 adult critical care units over 14 days and interventions were catergorised as an error, optimisation or consults, with pharmacy service demographics also being collected by investigator survey.
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