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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    The present research conducted a prospective observational study in 21 UK critical care units (CCU's) from 5-18 November 2012 with the aim to describe clinical pharmacist interventions. Data was collected via a web portal where specialist critical care pharmacists could make their reports, with each intervention classified as medication error, optimization or consult. A total of 20, 517 prescriptions were reviewed with 3294 interventions recorded during the weekdays. Results demonstrated that both medication error resolution and pharmacist-led optimisation rates were substantial.
  2. News Article
    A new study has found night shifts are "significantly associated" with health issues related to the heart, particularly atrial fibrillation, finding that women may be at a greater risk. The research, published in the European Heart Journal also found working night shifts is linked to an increased risk of coronary heart disease (CHD). “Night shift exposure also increased the risk of CHD (coronary heart disease) but not stroke or HF (heart failure). Whether decreasing night shift work frequency and duration might represent another avenue to improve heart health during working life and beyond warrants further study,” the paper said. Read full story. Source: The Independent, 16 August 2021
  3. News Article
    1,500 safety recommendations have been made to NHS trusts a year after hundreds of babies were left brain damaged and dozens of mothers and infants died. Safety watchdog Healthcare Safety Investigation Branch (HSIB) has outlined key themes from 760 investigations of maternity incidents, taking over investigations for NHS trusts in 2018 after concerns were raised over the poor quality of investigation by trusts and a lack of involvement in families. Sandy Lewis, associate director of maternity said: “The publication of the HSIB maternity programme year review provides crucial details of the work that has been undertaken in the last year. We would like to thank all of those who have worked with us in the past year, sharing their experiences, insights and expertise. Many families have not only told us their stories but have also trusted our investigators to reflect their perspectives and share their experience. Trusts have responded promptly to this insight, this has contributed to improving safer care of mothers, babies and families across the country.” Read full story. Source: The Independent, 16 August 2021
  4. News Article
    Providers fear 'fragmentation' of specialised services as NHS England begins delegating specialised services budgets to integrated care systems under reform plans. One leader of a specialist trust told HSJ: “There is a real risk of fragmentation. You can already see some of the conversations around various services around how people want to keep patients within their own ICS. There is the potential there for systems to buck the trend of centralising specialist services. Rather than bringing expertise and quality together, systems looking after budgets will look to set up their own specialist services.” Read full story (paywalled). Source: HSJ, 17 August 2021
  5. News Article
    Plasma from blood donations in England will be used to make a life-saving drug whilst also helping to secure NHS plasma stocks to make the antibody-based medicines, called immunoglobulins. The service will begin roll-out in the coming months, with other parts of the UK potentially following suit. Gerry Gogarty, from NHS Blood and Transplant, welcomed the decision, calling it a huge step forward. "By recovering plasma from blood donations, we can improve long-term supplies of immunoglobulin medicine, and each generous blood donation will go even further in helping to save the lives." Read full story. Source: BBC News, 17 August 2021
  6. Content Article
    This article discusses what advocacy actually entails and what values it ought to embody. The paper considers whether advocates are necessary since not only can they be dangerously paternalistic, but the salutary values advocacy embodies are already part of good professional health care.
  7. Content Article
    This article by Dean K Wright describes the definition of 'advocate' and discusses how a doctor can best support their patient, particularly in regards to advocating for their patients rights and/or needs and in cases of child abuse and barriers to effective patient care.
  8. News Article
    According to reports, Barts Health Trust and most other providers in the north east London health system may run out of blood tube collection products by the end of August. Though, according to notes seen by HSJ, a “mitigation plan with demand management in place this may extend into September”. After warning colleagues in north east London that the shortage of blood collection tubes made by Becton Dickinson affects “all NEL areas” except acute trust Barking, Havering and Redbridge University Hospitals Trust, Diane Jones, chief nurse of the NEL integrated care system has said “NHSE are looking at mitigations, but nothing confirmed as yet, and [they] may take a few weeks to come on stream. The mitigation may get us up to 50 per cent of usual supply in the short term.” Read full story (paywalled). Source: HSJ, 13 August 2021
  9. News Article
    Coroners have raised multiple concerns that visiting restrictions are having a damaging effect on patient care and wellbeing, also raising the issue that families of vulnerable patients may be unable to pass on information to clinicians which would be relevant to their care. NHS Providers chief executive Chris Hopson said: “No trust makes the decision to suspend or restrict visiting lightly. Trust leaders understand the importance of allowing visitors, in a safe and manageable way, or finding alternative ways to enable particularly vulnerable patients to stay in touch with their families and carers. They are also aware of the important information that families and carers can provide about patients.” Read full story (paywalled). Source: HSJ, 16 August 2021
  10. News Article
    A hospital in Yorkshire has suspended all routine inpatient surgeries amid overcrowding in A&E caused by a lack of beds. Staff at the Mid Yorkshire Hospitals NHS Trust were told in an email that this had been a "critical issue for too long." “It is with regret that this decision has had to be made given that it will result in less patients receiving surgical treatment, slowing down our progress on reducing waiting times. However, the extreme pressure on beds has to be reduced and quickly. The trust consistently has between 25 and 50 patients waiting for a bed at any one time at Pinderfields emergency department, causing serious overcrowding and long delays [and] contributing to an unacceptable patient and staff experience.” Martin Barkley, chief executive of the trust, told staff. Read full story. Source: The Independent, 14 August 2021
  11. News Article
    The new head of NHS England has urged people not to ignore the signs of cancer and encourages people to get checked out if symptoms emerge, such a cough or stomach pain that won't go away. Experts believe certain cancers such as abdominal cancers - throat, stomach, bowel, pancreatic, ovarian - and urological cancers - prostate, kidney and bladder - are the most likely to go unrecognised and suggest anyone with symptoms to tell their GP. "People should not feel like they cannot trouble the NHS, which is open and ready to treat people." NHS England chief executive Amanda Pritchard has said. Read full story. Source: BBC News, 15 August 2021
  12. Content Article
    The efficacy of injection therapy in diabetes depends on correct injection technique. The aim of the Insulin Injection Technique Questionnaire was to understand how people with diabetes inject, so that guidance can be tailored towards improving injection technique. This article in the Journal of Diabetes analyses the results of the 2008-2009 survey and identifies areas where improvements have been made since the last survey, and areas where there is still progress to be made.
  13. Content Article
    This research article aimed to provide Registered Nurses with a description of patient advocacy in the clinical setting. Through a series of semi-structured interviews with 25 participants, the results of this study found the nurses had an adequate understanding of patient advocacy and were willing to advocate for patients, describing patient advocacy as promoting patient safety and quality care.
  14. Content Article
    This article by Angira Patel discusses the importance of health advocacy and a clinicians professional responsibility towards their patients. Angira also describes current attitudes and practices surrounding advocacy, particularly within the political and social sphere.
  15. Content Article
    In this blog Patient Safety Learning outlines the key points included in its response to the consultation on establishing a Patient Safety Commissioner for England. This sets out their feedback to this consultation and describes the powers and resources this role will require if it is to effectively influence change and improve patient safety.
  16. News Article
    Performance data published by NHS England has revealed a big surge in the number of immediately life-threatening incidents ambulance services have responded to. The data also showed average response times have increased and a large number of patients are attending emergency departments. So far, the reason for the increase remains unclear, however, a potential factor could be the return of respiratory illnesses, particularly in children, as the lockdown has eased. In a statement Association of Ambulance Chief Executives said, ”The reasons for the demand increases are complex and will include some patients who have not accessed care as early as they might have done normally and therefore present to the ambulance service as a high acuity patient and many patients who are contacting us for lower acuity issues which in some cases could have been managed by accessing other parts of the UEC system. We continue to work closely with NHS England to mitigate the demand as much as possible and encourage sign-posting of patients to other parts of the UEC system when that is a safe and more appropriate solution to their problem.” Read full story (paywalled). Source: HSJ, 12 August 2021
  17. News Article
    Latest data has revealed more than one million 999 calls were placed in July, showing paramedics were sent out to 82,000 emergencies last month and 8,000 more than the record set in June. This comes after A&E departments became overwhelmed with an influx of new patients over the summer, with many hospitals having to cancel operations due to being dangerously understaffed. Dr Katherine Henderson, president of the Royal College of Emergency Medicine has said, "The NHS has been running hot for months now and these figures show we are nearly at boiling point. We are worried that the public think things are getting back to normal on the virtual eve of a further reduction in restrictions, and messages from the centre that say things are OK are disingenuous – the reality is that the health service is really struggling." Read full story. Source: The Independent, 12 August 2021
  18. News Article
    At a virtual event held by The Independent last night, experts agreed maternity services needed to be overhauled. The panel discussion, NHS maternity scandal: Inside a crisis, laid out the facts surrounding the problems around maternity care and concerns around safety amid repeated examples of poor care in multiple cases. Donna Ockenden, a senior midwife who has been leading the inquiry into maternity services at Shrewsbury and Telford Hospitals explained "I think one of the major issues around maternity services is that we’re not treated in the same way as A&E. I think that people fail to see that actually, maternity is a woman’s A&E department, you can start a shift in any maternity unit, you can plan what you think you’re going to do. But actually you don’t know what is going to come in the front door.” Read full story. Source: The Independent, 12 August 2021
  19. News Article
    New analysis looking at the spread of Covid-19 in hospitals has revealed a massive gulf in ability to contain the virus during the first wave. According to the published data, overall only 1 in 10 people actually caught the virus whilst in the hospital, however 314 UK hospitals showed that ranged from just one in 100 cases caught in hospital, to more than 1 in 4, with an estimate of between 5,700 and 11,900 people who were infected in hospital. Professor Calum Semple, one of the researchers from the University of Liverpool has said, "There will be tragedy behind this story, people that came into hospital with one problem, caught Covid and sadly died." Read full story. Source: BBC News, 13 August 2021
  20. News Article
    New figures show a record number of 5.45 million people are waiting for NHS hospital treatment in England, with many more joining the waiting list who also need treatment, and those who came back to the NHS for healthcare having not done so during the worst periods of the pandemic. Sajid Javid, the Health Secretary has said, "We estimate there's probably some seven million people that ordinarily would have come forward to the NHS that stayed away, understandably, during the height of the pandemic. We want those people to come back. I don't know how many will come back but, even if half of them came to the NHS - and can I just stress I really want people that need to be seen by the NHS to know the NHS is there for them and they should come forward - but as they do I think waiting lists will rise because there will be a huge increase in demand." Read full story. Source: BBC News, 12 August 2021
  21. Content Article
    This article by Robin Aldwinckle discusses the case study of a 61-year-old male patient with severe knee osteoarthritis and hypertension who was admitted for surgery under subarachnoid regional anesthesia. However at the end of the procedure, the patient remained unresponsive and was subsequently diagnosed with Local Anesthetic Systemic Toxicity (LAST). Whilst the patient recovered, this case highlights a lack of communication between the operating room team members concerning the safe dosing of local anesthetics and that the correct diagnosis and treatment of LAST in the operating room is critically important.
  22. Content Article
    This research article focuses on the patient safety aspects of handling and recognising allergic reactions and severe perioperative anaphylaxis, and discusses the basic approach of the allergic patient and of patients with a suspected allergy to perioperatively administered medication.
  23. Content Article
    This article on sex and gender differences discusses the definitions, general and perioperative implications and how acknowledging differences between men and women relevant to anesthesia is of paramount importance to ensuring perioperative patient safety.
  24. Content Article
    This article describes the case studies of a 65-year-old woman with a history of acute myeloid lymphoma called her oncology physician's office with symptoms of chemotherapy-induced nausea and a 66-year-old woman was prescribed estradiol vaginal tablets for post-menopausal symptoms. Cynthia Li and Katrina Marquez discuss how both patient cases resulted from human error by pharmacy staff and how although most medication errors can be directly attributed to human error, human error is often a result of poor system design and recommend 'The 8 R's' approach to reduce the risk for errors includes development of safeguards at every level of the medication use process.
  25. News Article
    According to the state's health watchdog Health Information and Quality Authority (Hiqa), six out of 10 hospitals inspected last year were non-compliant with aspects of infection-control procedures against Covid-19. Recurring issues such as poor physical infrastructure, capacity issues and workforce challenges were found to hinder efforts to cope with the pandemic, and despite investments, issues around infrastructure and capacity have been worsened by the pandemic. “In most instances, we found an effective approach to adapt to this unprecedented crisis in hospitals. However, hospitals’ efforts were made more difficult due to underlying historic problems with infrastructure, limited bed capacity and unequal or limited access to specialist workforce input and advice – problems that Hiqa’s prior monitoring work against national standards has consistently highlighted.” said Hiqa’s director of regulation, Mary Dunnion. Read full story. Source: Irish Times, 10 August 2021
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